Agri 2020-3

Cilt - Volume 32

ISSN 1300-0012

Sayı - Number 3 Temmuz - July 2020

A RI PAIN TÜRK ALGOLOJİ (AĞRI) DERNEĞİ’NİN YAYIN ORGANIDIR THE JOURNAL OF THE TURKISH SOCIETY OF ALGOLOGY

KARE

Index Medicus-Medline, Web of Science - ESCI, EMBASE/Excerpta Medica, Gale, EBSCO, CINAHL ve TÜBİTAK-ULAKBİM tarafından dizinlenmektedir.

(Included and Indexed in Index Medicus-Medline, Web of Science - ESCI, EMBASE / Excerpta Medica, Gale, EBSCO, CINAHL and the Turkish Medical Index).

www.agridergisi.com

Cilt - Volume 32 Sayı - Number 3 Temmuz - July 2020

ISSN 1300-0012

A RI PAIN TÜRK ALGOLOJİ (AĞRI) DERNEĞİ’NİN YAYIN ORGANIDIR THE JOURNAL OF THE TURKISH SOCIETY OF ALGOLOGY

Index Medicus-Medline, Web of Science, ESCI, EMBASE/Excerpta Medica, Gale, EBSCO, CINAHL ve TÜBİTAK-ULAKBİM tarafından dizinlenmektedir.

(Included and Indexed in Index Medicus-Medline, Web of Science, ESCI, EMBASE / Excerpta Medica, Gale, EBSCO, CINAHL and the Turkish Medical Index).

www.agridergisi.com

A RI PAIN Editör (Editor-in-Chief ) Gül KÖKNEL TALU Yardımcı Editör (Associate Editor) Ruhiye REİSLİ Bilimsel Danışma Kurulu (Editorial Board) Akgün K Turkey Antonaci F Italy Babacan A Turkey Cahana A Switzerland Çamcı E Turkey Erdine S Turkey İnan L Turkey İnan N Turkey Ketenci A Turkey Kress H Austria Morlion B Belgium Oral E Turkey Özge A Turkey

Özyalçın S Turkey Peker S Turkey Şentürk M Turkey Talu U Turkey Tan E Turkey Unal Çevik I Turkey Uyar M Turkey Vadalouca A Greece van Kleef M Netherlands Varrassi G Greece Vissers K Netherlands Yücel B Turkey

Cilt (Volume) 32, Sayı (Number) 3, Temmuz (July) 2020 p-ISSN 1300 - 0012 e-ISSN 2458-9446 Türk Algoloji (Ağrı) Derneği’nin Yayın Organıdır (The Journal of the Turkish Society of Algology)

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Üç Ayda Bir Yayınlanır (Published Quarterly) Sahibi ve Yazı İşleri Müdürü (Ownership and Accountability for Contents) Gül KÖKNEL TALU Türk Algoloji (Ağrı) Derneği The Turkish Society of Algology Başkan (President)

N. Süleyman ÖZYALÇIN

Üyeler (Members)

N. Süleyman ÖZYALÇIN Sema TUNCER UZUN Kenan AKGÜN Levent Ertuğrul İNAN Güngör Enver ÖZGENCİL Hayri Tevfik ÖZBEK Meltem UYAR

İletişim (Correspondence) Editör ve Yazı İşleri Müdürü (Editor-in Chief)

Gül KÖKNEL TALU

Yardımcı Editör (Associate Editor)

Ruhiye REİSLİ

Yürütücü Sekreter (Executive Secretary)

Gül KÖKNEL TALU

Adres (Mailing Address)

Tel (Phone) Faks (Fax) e-posta (e-mail) web

İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Algoloji Bilim Dalı, Çapa 34390 İstanbul, Turkey +90 - 212 - 531 31 47 +90 - 212 - 631 05 41 gktalu@yahoo.com www.algoloji.org.tr

Index Medicus-Medline, Web of Science, ESCI, EMBASE/Excerpta Medica, Gale, EBSCO, CINAHL ve TÜBİTAK-ULAKBİM tarafından dizinlenmektedir.

(Included and Indexed in Index Medicus-Medline, Web of Science, ESCI, EMBASE / Excerpta Medica, Gale, EBSCO, CINAHL and the Turkish Medical Index).

Yayıncı (Publisher) KARE YAYINCILIK | karepublishing

KARE Concord İstanbul, Dumlupınar Mah., Cihan Sok., No: 15, B Blok 162, Kadıköy, İstanbul, Turkey Tel: +90 216 550 61 11 Faks (Fax): +90 216 550 61 12 e-posta (e-mail): kareyayincilik@gmail.com / kare@kareyayincilik.com www.kareyayincilik.com Yayın Türü (Type of Publication): Süreli Yayın (Periodical) Basım Tarihi (Press Date): Temmuz 2020 (July 2020) Sayfa Tasarımı (Design): Ali CANGÜL Baskı (Press): Filmevi Online Dergi (Web): LookUs

www.agridergisi.com

Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur (This publication is printed on paper that meets the international standart ISO 9706: 1994)

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İLGİ ALANI VE AMACI Bu dergi Türk Algoloji (Ağrı) Derneği’nin süreli yayın organıdır. Üç ayda bir yayımlanır.

Ağrının yapısı, mekanizmaları ve tedavisi ile ilgili özgün araştırmalar yayınlanır. Multidisipliner bir yaklaşım ile ağrı ile ilgili temel ve klinik bilimlerde yapılan araştırmaların geniş kitlelere yayılması için bir forum oluşturulmaya çalışılır. Dergide yayımlanan makaleler Türk Algoloji Derneği’nin resmi görüşünü temsil etmez. Yayımlanan makale ve şekiller derginin malı olur.

GENEL AÇIKLAMALAR 1. Dergi Türkçe ve İngilizce olarak yayınlanır.

2. Editoryal Kurul tarafından uygun görülen metinler yayımlanır. Editoryal Kurul, yayın kurallarına uymayan metinleri yayımlamamaya ve düzeltilmek üzere yazarına geri göndermeye yetkilidir. “Derleme” kategorisindeki yazılar, Editoryal Kurul tarafından belirlenen yazarlardan yapılan istek üzerine kabul edilmektedir. Editoryal Kurul tarafından istenmedikçe bu kategoriler için yazı gönderilmemelidir. Ancak bu konuda editöre öneride bulunulabilir. Tüm yazılarda editöryel değerlendirme ve düzeltmeye başvurulur; gerektiğinde, yazarlardan bazı soruları yanıtlanması ve eksikleri tamamlanması istenebilir. Dergide yayınlanmasına karar verilen yazılar “manuscript editing” sürecine alınır; bu aşamada tüm bilgilerin doğruluğu için ayrıntılı kontrol ve denetimden geçirilir; yayın öncesi şekline getirilerek yazarların kontrolüne ve onayına sunulur.

3. Dergi, uluslararası tıbbi dergi editörleri kurulunca hazırlanan “Biyomedikal dergilere teslim edilecek metinlerde aranan ortak özelliklerin” 3. baskısındaki (1983) kurallara uygun olarak hazırlanmamış yayın metinlerini kabul etmez. Metinler teslim edilmeden once bu kuralların yayınlandığı British Medical Journal 1988;296:401-5 veya Annuals of Internal Medicine 1988;108:258-65’e bakılmalıdır.

4. Dergiye yazı gönderilmesi sadece internet üzerinden yapılmaktadır. Bunun için resmi web sitesi olan www.agridergisi.com adresindeki ilgili basamaklar takip edilmelidir.

5. Yayınlanması istenen metnin dayandığı çalışma, daha önce başka yerde yayınlanmış veya yayınlanmak üzere teslim edilmiş veya kabul edilmiş olmamalıdır. Özet biçiminde yayınlanmış bir ön bildirinin bitmiş haline yer verilebilir.

6. Dergide yayınlanan yazılar için telif hakkı ödenmez. Bu nedenle başvuru mektubunda telif hakkının dergiye bırakılacağı açıklanmalı ve metnin tüm yazarlarca okunduğunu ve onaylandığını belirten bir ifade bulunmalıdır.

7. Yayımlanmış şekil vb. gereçlerin yerinde basılabilmesi, tanınabilecek kişilerin resimlerinin kullanılabilmesi ve katkılarından dolayı kişilerin adlarının belirtilebilmesi için alınmış izinler posta ile ulaştırılmalıdır.

8. Yazarlar teslim ettikleri her şeyin birer kopyasını saklamalıdır.

9. Teslim edilmiş bir metnin tümünün veya bir bölümünün başka bir yerde yayımlanması söz konusu olursa Editoryal Kurul’a bilgi verilmesi zorunludur.

10. Araştırmalar için, ilgili kurumun bağlı bulunduğu etik komitenin onayının alınmış olması şarttır. Bu durum “gereç ve yöntem” bölümünde belirtilmelidir.

11. Yayımlanan yazıların sorumluluğu yazarlarınındır.

12. Yazarlara tıpkıbasım gönderilmeyecektir. İSTENEN DOSYA TÜRLERİ VE MİNİMUM YAZI TESLİM GEREKLİLİKLERİ Elektronik gönderim sistemiyle yazıların tesliminden önce aşağıdaki formatlama özelliklerine göre ayrı ayrı MS Word (.doc) ve Adobe (.pdf ) dosyaları hazırlanmalıdır. Başvuru mektubu ve başlık sayfası olmayan hiçbir yazı kabul edilmeyecektir.

1. Başvuru mektubu: Her türden yazının gönderimi mutlaka bir başvuru mektubunu içermelidir. Başvuru mektubunda yazar(lar) başlık, yazının türü ve yazının gönderim kategorisi ve gönderilen çalışmanın daha önce bir bilimsel bir toplantıda sunulup sunulmadığını belirtmelidir. Bu başvuru mektubu yazı AGRI Dergisi tarafından incelenme sürecindeyken başka bir yerde yayınlanmayacağı veya yayınlanmak üzere değerlendirilmeyeceğine ilişkin bir açıklama içermelidir. Ayrıca başvuru mektubunun alt kısmında yazışmadan sorumlu yazarın tam adı, adresi, telefon numarası ve e-posta adresi dahil iletişim bilgileri verilmelidir. Başvuru mektubu yazışmadan sorumlu yazar tarafından imzalanmalı, tarayıcıdan geçirilmeli, yazının diğer dosyalarıyla birlikte jpg veya .pdf formatında sunulmalıdır. Başvuru mektubu aşağıdaki gibi düzenlenmelidir: a. Başlık, yazının türü. b. İncelenme sürecindeyken başka bir yerde yayınlanmayacağı veya yayınlanmak üzere değerlendirilmeyeceğine ilişkin bir açıklama. c. Yazışmadan sorumlu yazar(lar)ın tam adı, adresi, telefon numarası ve e-posta adresi dahil iletişim bilgileri. d. Yazışmadan sorumlu yazarın imzası.

2. Başlık sayfası: Gönderilen tüm yazı türleri başlık sayfası dosyasına dahil edilmelidir. Lütfen başlık sayfanızı aşağıdaki unsurları da içeren ayrı bir elektronik dosya şeklinde hazırlayın. a. Yazının başlığı. b. Yazar (Yazarların listesi) lütfen yazarların tam adlarını ve her bir yazar için en fazla iki akademik dereceyi belirtin. Bir kurumda üyelik gibi onursal bağlantıları bu listeye dahil etmeyin. c. Her bir yazarın çalıştığı anabilim dalı veya bölüm, kurum, şehir ve ülke gibi bağlantıları. d. Yazışmalardan sorumlu yazarın (yazarların) tam adı, adresi, telefon numarası ve e-posta adresi gibi iletişim bilgilerini kaydedin. e. Fon tedariki veya başka mali destek hakkında bilgi verilmelidir. f. Çıkar çatışması beyanı: Başlık sayfasının en alt kısmında çıkar çatışması beyanı bulunmalıdır. Lütfen, her bir yazar için ICMJE önerilerine (ICMJE Recommendations) uygun biçimde tüm potansiyel çıkar çatışmaları listesi kaydedilmelidir. Çıkar çatışması yoksa lütfen “Çıkar çatışmaları: Beyan edilmemiştir” ibaresini koyun.

3. Özetler: Özetler sayfasına yazar(lar) sırasıyla özet ve anahtar sözcükler (en az 3 sözcük) yazılmalıdır. Anahtar sözcüklerin Medical Subject Headings (MeSH) (http://www.nlm.nih.gov/mesh/MBrowser.html) standartlarına uygun ve Türkiye Bilim Terimleri’nden (http://www.bilimterimleri.com) seçilmiş olması gerekmektedir.

4. Ana Metin: Gönderilen her yazı türü için bir ana metin dosyası bulunmalıdır. Bu dosya başlık, özetler sayfası, yazınızın ana metni ve tek bir elektronik dosya haline getirilmiş kaynaklar bölümünü içermelidir. Kaynaklar bölümünden sonra tablolar da ayrı sayfalar halinde bu dosyaya konulabilir veya tercihinize göre ayrıca elektronik ortama yüklenebilir. Ana metnin yapısı yazının türüne göre farklılık gösterir. Tablolarla birlikte veya yalnız başına özetler, anahtar sözcükler, ana metin, kaynakları içeren bu birleşik dosya orijinal yazının kimliklerin gizlenmiş olduğu versiyonudur. Yazarların adları, akademik ünvanları, kurumları ve adresleri yazılmaz. Yazının değerlendirme süreci istisna olmak üzere, yazara (yazarlara) ilişkin herhangi bir bilgi içeren yazılar farkına varılır varılmaz rededilecektir.

5. Tablolar: Verileri özetleyen tablolar herhangi bir şablon kullanmaksızın net biçimde formatlandırılmalıdır. Tablolardaki veriler tümüyle metin içinde belirtilmemelidir. a. Tablolar ardışık sırayla numaralandırılmalıdır. b. Metinde her bir tabloya referans verilmiş olunmalıdır. c. Her bir tablonun numarası ve başlığı tablodan önce her sayfanın başına yazılmalıdır. d. Tablolar kaynaklar bölümünden sonra ayrı sayfalar halinde bu dosyaya konulabilir veya tercihinize göre ayrıca elektronik ortama yüklenebilir. Tablolar MS Word (.doc) formatında yüklenmeli ve elektronik dosya buna göre adlandırılmalıdır (Tablolar_xxx_vx.doc). Tablolar pdf, jpeg veya başka bir formatta yüklenmemelidir.

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6. Şekiller: Yazıda şekiller varsa, her yazı türü için her bir Şekil ayrı bir dosya halinde yüklenmelidir. Şekil/görüntülerdeki bilgiler tümüyle tekrar edilmemeli, metinde şekil/görüntüye gönderme yapılmalıdır. a. Teknik gereklilikler i. Şekil alt yazıları kaynaklar bölümünden sonra ayrı bir sayfada belirtilmelidir. ii. Yazı gönderimi sırasında şekillerin hepsi metin dosyasından ayrı bir dosyaya yüklenmeli ve buna göre adlandırılmalıdır (Şekil 1_xxx; Şekil 2_xxx). iii. Şekillerin içine herhangi bir alt yazı veya başlık dahil edilmemelidir. iv. Resimler JPEG, EPS veya TIFF formatında saklanmalıdır. v. Lütfen fotograflar ve şekilleri en azından 300 nokta/inç çözünürlükte gönderin. TIFF veya EPS formatında gönderilen şekilleri son derece kolay işlemekteyiz. b. Etik gereklilikler i. Fotoğrafın sahibi ve/veya fotografı çekilen hasta onam formunu imzamalıdır. İzin alınmadan başka kaynaklardan şekiller kopyalanmamalıdır.

7. Açıklamalar, izinler ve imzalar a. Çıkar Çatışması Formu: Esas ilgilenilen konuya (hastaların iyilik hali veya araştırmanın geçerliliği) ait mesleki bir karar ikincil bir ilgi kaynağından (örn maddi kazanç) etkilenebildiğinde çıkar çatışması söz konusudur. Finansal ilişkiler kolayca saptanabilir. Ancak kişisel ilişkiler veya rekabetler, akademik yarışmalar veya entelektüel inanışlar nedeniyle de çatışmalar oluşabilmektedir. Çatışma gerçek veya potansiyel olabilir. En güvenli süreç Editöre tam olarak beyan etmekten geçer. Çatışmaları açıklamamak bir Erratum (yazım hatası) hatta yazının geri çekilmesine yol açabilmektedir. AGRI Dergisine gönderilen yazıların hepsinde potansiyel veya halen mevcut çıkar çatışmaları olduğu düşünülen tüm ilişkilerin beyan edilmiş olması gerekir. Yazarların hepsinden çıkar çatışmalarını beyan etmeleri istenir. b. Hasta Onam Formu: Hayatta olan tanımlanabilir bir hastaya ait kişisel bilgilerin yayınlanması hasta veya hamisinin açıkça onam vermesini gerektirir.

Yazarlardan Kaynaklar menüsündeki Formlar, Şablonlar ve Örnekler sayfasında bulunan standart bir hasta onam formunu kullanmalarını bekleriz. c. Telif Hakkının Nakli Formu: Yazarların tümünden telif hakkının nakli formunu doldurmaları istenir.

YAZININ FORMATLANMASI Yazının formatı 2013 Ağustosunda güncellenmiş ICMJE Tıp dergilerinde Bilimsel Çalışmaların Yürütülmesi, Raporlanması, Yayına hazırlanması ve Yayınlanması (ICMJE-Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals) kriterlerine uyumlu olmalıdır. Derginin formatına uymayan yazılar daha fazla gözden geçirilmeden düzelti için yazara iade edilecektir. O halde zaman ve emek kaybından kaçınmak için dergi gönderim kuralları dikkatlice gözden geçirilmelidir.

Yazının çatısı WAME kılavuzlarıyla (guidelines of WAME) uyumlu olmalıdır.

Genel Format 1. Genel Yazı Stili: Yazı Microsoft WordTM formatında tek sütun halinde yazılmalıdır. Tıbbi jargonlardan kaçınmak için her çaba gösterilmelidir.

2. Tanıtıcı Bilgilerin Gizlendiği İlk Gözden Geçirme: Yazarların adları ve akademik ünvanlar, kurumlar ve adresler gibi tanımlayıcı bilgiler gizlenir. Yazara (yazarlara) ait herhangi bir bilgi içeren yazılar rededilecektir.

3. İlaçlar: İlaçların jenerik adları kullanılmalıdır. Dozlar ve uygulama yolları belirtilmelidir. Ana metinde bir ilaç, ürün, bilgisayar donanım veya yazılımından söz edildiğinde, ürünün adı, üreticisi, firmanın bulunduğu il ve ülke gibi ürün bilgileri aşağıdaki formata göre parentez içinde belirtilmelidir [“Discovery St PET/CT scanner (General Electric, Milwaukee, WI, ABD)]” 4. Kısaltmalar: En gerekli olanlar dışında kısaltma kullanılmasını teşvik etmemekteyiz. Yazar için kolaylık olabilmesine rağmen kısaltmalar genellikle okuyucunun yazıyı kolayca anlamasını engeller. Kısaltmaların tümü ilk kez kullanıldığı anda tanımlanmalı (hem özette, hem de ana metinde) ve kısaltmalar tanımlamadan sonra parentezler içinde gösterilmelidir. Yazarlar başlık ve özette kısaltmalar kullanmaktan kaçınmalı, ana metinde de kullanımları sınırlandırılmalıdır.

5. Ondalık noktalar veya virgüller: Ondalık sayılar tam sayılardan noktalarla ayrılmalıdır. Yazı boyunca ondalık sayılar için virgül kullanmayınız.

6. Kaynaklar: Kaynaklar metin içinde ilk kez yazıldığı sırayla art arda numaralandırılmalıdır (6 yazardan sonra ve ark. kullanın). Özetleri kaynak göstermekten veya kamu kaynaklarında mevcut olmayan esaslı bilgiler sağlamadıkça “kişisel konuşmadan” alıntı yapmayın. Kaynak göstermeye ilişkin örnekler aşağıda gösterilmiştir: o Makale: Süleyman Ozyalçin N, Talu GK, Camlica H, Erdine S. Efficacy of coeliac plexus and splanchnic nerve blockades in body and tail located pancreatic cancer pain. Eur J Pain 2004;8(6):539-45. o Kitap: Newton ML. Current practice of pain. 1st ed. St. Luis, MO: Mosby; 1990. o Kitaptan bölüm: Turner JA. Coping and chronic pain. In: Bond MR, Charlton JE, Woolf CJ, editors. Pain research and clinical management. Proceedings of the VIth world congress on pain. Amsterdam: Elsevier; 1991. p. 219-27. o Kurslar ve konferanslar (yayınlanmamış): Erdine S. Pain. Course lecture presented at: International Pain Congress, June 7, 2008, İstanbul.

YAZI TÜRLERİ VE SPESİFİK FORMATLAMA KILAVUZLARI Makalenin türü, formatlama ve yazının sözcük sayısı dahil kullanılması gereken kılavuzları belirlediğinden yazı gönderiminde ilk adım makalenin türünün tanımlanmasıdır.

Araştırma Makalesi: Ağrıda temel bilimler ve klinik araştırmalara ait özgün çalışmalar: Bu makaleler randomize kontrollü çalışmalar, gözleme dayalı çalışmaları (kohort, olgu-kontrollü veya kesitsel), tanısal doğruluk çalışmaları, sistematik derlemeleri ve metaanalizleri, randomize olmayan davranışsal ve halk sağlığı girişimsel çalışmaları, deneysel hayvan çalışmaları veya başka klinik ve deneysel çalışmaları içerebilir. Araştırma makaleleleri aşağıda belirtilen sayfaları, bölümleri ve yukarıda gerekli dosya türleri bölümünde tanımlanmış dosyaları içermelidir: 1. Özetler Sayfası: Hem İngilizce hem de Türkçe özetlerin olması gerekir. Özetler 250 sözcüğü geçmemeli ve aşağıdaki alt başlıklar halinde yapılandırılmalıdır: Amaçlar, Gereç ve Yöntemler (çalışma tasarımıyla birlikte), Bulgular ve Sonuç (olgu kontrollü çalışma, kesitsel çalışma, kohort çalışması, randomize kontrollü çalışma, tanısal doğruluk çalışmaları, metaanalizler, ve sistematik derleme, hayvan deneyleri, randomize olmayan davranışsal ve halk sağlığı girişimsel çalışmaları vs). İstatistiksel analize göre bulgularınızın önemini vurgulayın ideal olarak etki büyüklüğü ve başlıca sonuçlar için güven aralıklarını da bulgulara dahil edin.

2. Ana Metin: Ana metin şu alt başlıklar halinde yapılandırılmalıdır: Giriş, Gereç ve Yöntemler, Bulgular, Tartışma, Teşekkür, Kaynaklar, Tablolar ve Şekil Alt Yazıları. a. Giriş: Üç paragraflı yapı kullanılmalıdır. Çalışma konusuna ilişkin arka plan bilgileri (1. paragraf ), çalışmanın bağlamı ve çıkarımları (2. paragraf ), çalışmanın varsayımları ve hedefleri (3. paragraf ). Arka plan: Ortamı oluşturan ve sizi konuyu araştırmaya sevk eden koşullar veya tarihsel bağlamı

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tanımlayın. Bağlam: Araştırmanızın niçin önemli olduğunu, potansiyel çıkarımlarının neler olduğunu, ilk paragrafta ortaya atılan konularla ilişkisini, bu spesifik araştırmanın niçin bir sonraki mantıksal adım olduğunu, çalışmanın hedeflerini anlatın ve araştırmanın spesifik amacını veya varsayımını ve birincil sonuç ölçümünüzü açıkça belirtin. b. Gereç ve Yöntemler: Yöntem bölümü özgün araştırma makalelerinin en önemli bölümlerinden biri olup yeterince detaylandırılmalıdır. Araştırma yöntemi, çalışma örneği, uygulanmış analizler, kullanılan ticari istatistik programları, ölçüm ve değerlendirmelerin ayrıntıları (örn: biyokimyasal test cihazları ve kitlerin markası ve modeli) tümüyle açık ve net biçimde belirtilmelidir. Prospektif çalışmalar için yerel etik komite ve diğer onay veren yetkili kurumların adları da Yöntemler bölümünde verilmelidir. Yöntemler bölümü mantıksal ve ardışık alt başlıklar şeklinde düzenlenmelidir. c. Bulgular: Çalışma popülasyonunun demografik özellikleri ve hipotez testinin ana ve ikincil bulguları da kaydedilmelidir. Bu bölümde bulguları yorumlamaktan ve literatür bulgularını tartışmaktan kaçınılmalıdır. Analizlerde edinilmiş olabildiğince çok veriyi bir bütün olarak mümkünse grafikler halinde sunun. Testlerde kullanılan istatistikler temelinde bulguların önemini vurgulayın. Bunun için ideal olarak her bir sonuç için etkinin büyüklüğü ve ilişkili %95 güven aralıklarından yararlanın. d. Tartışma: Çalışmanın birincil ve ikincil sonuçları kısaca sunulmalı, literatürdeki benzer bulgularla karşılaştırılmalıdır. Bu bölümde yoğun arka plan bilgileri vermektem kaçınılmalıdır. Yalnızca sonuçlarınızın yorumlanmasıyla doğrudan ilişkili yayınlanmış makaleleri göz önünde bulundurun ve bunları çalışma bağlamına dahil edin. İstatistiksel anlamı klinik önemden fazla vurgulamayın. Bulgularınızı araştırmanızda açıkça incelemediğiniz toplumlar ve koşullara uyarlamayın. Yöntemler ve Bulgular bölümlerinde formel bir maliyet-etkililik analizi sunmadıysanız maliyet ve ekonomik yarar konularında iddialarda bulunmayın. Bir sonraki aşamanın ne olduğunu spesifik olarak belirtmeden. “Daha fazla araştırma gereklidir” önerisinde bulunmayın. İsterseniz “Geriye baktığımızda …” ile başlayan bir paragraf ilave edip içtenlikle çalışmayı tekrarlama fırsatı verilseydi neleri farklı yapmak isterdiniz konusunu tartışarak başkalarının da deneyimlerinizden bir şeyler öğrenebilmesini sağlayabilirsiniz. e. Limitasyonlar: Çalışmanın limitasyonları tartışma sonunda ayrı bir paragraf içinde “Limitasyonlar” altbaşlığı altında belirtilmelidir. Sonuçlarınızın içsel ve dışsal geçerliliğini tehdit eden etmenler de dahil olmak üzere çalışmanızın limitasyonlarını açıkça tartışın. Mümkünse her bir yanlılığın boyut ve yönünü ve sonuçların yorumlanmasını nasıl etkileyebildiğini inceleyin. f. Sonuç: Çalışmanın bulguları ışığında net bir sonuca varılmalıdır. Çalışma sonuçlarının güncel klinik uygulamalar üzerine potansiyel etkileri tek bir cümleyle belirtilmelidir. Çalışmanın sonuçlarıyla desteklenmeyen çıkarımlarda bulunmaktan kaçınılmalıdır. g. Teşekkür: h. Kaynaklar: Kaynaklar ayrı bir sayfada belirtilmelidir. i. Şekil Alt yazıları: Şekil alt yazıları ayrı bir sayfada ana metin içinde belirtilmeli ve bu sayfa ana metin dosyasının sonuna konmalıdır. j. Tablolar: Ana metin dosyasının sonuna ayrı sayfalar veya ayrı bir dosya şeklinde konmalıdır. k. Şekiller: Ana metin dosyasının içine konmamalı ve yukarıda gerekli dosya türleri bölümünde tanımlandığı gibi ayrı dosyalar halinde yüklenmelidir. l. Etik ve İnceleme Kurulunun Onayı: Yazınız orijinal araştırma ise bir kurumsal inceleme veya etik kurul tarafından onaylandığı veya muaf tutulduğunu doğrulamanız istenecektir. AĞRI Dergisi onaylanmamış veya muaf tutulmamış yazılara daha fazla dikkate almayacaktır. (Yalnızca daha önce IRB (bağımsız etik kurul) onay veya muafiyeti bulunan üçüncü tarafların anonim veri tabanlarının analizleri bu kapsamın dışındadır.)

Olgu Raporları: Ağrı pratiğinde nadiren rastlanılan ve eğitsel değeri olan klinik olgular veya komplikasyonların kısa anlatımlarıdır. Mevcut literatürde daha önce belgelenmemiş klinik durumları, klinik belirtileri veya komplikasyonları, bilinen tedavi rejimlerinin raporlanmamış yan veya advers etkileri konusunda ileri araştırmayı tetikleyebilen bilimsel bulgular göz önünde bulundurulacaktır. Olgu raporlarının özetleri 150 sözcüğü geçmemeli, ayrı bir sayfaya yazılmalı ve yapılandırılmamalıdır. Olgu serilerinin ana metni aşağıdaki alt başlıklar altında yapılandırılmalıdır: Giriş, Olgu Sunumları, Tartışma ve Kaynaklar.

Kısa Rapor: İlk elde edilen veriler, bulgular veya ileri araştırmaların gerekliliğini gösteren küçük çaplı çalışmaların orijinal raporları. Özetler 250 sözcüğü geçmemeli ve araştırma makalesi şeklinde yapılandırılmalıdır. Limitasyonları, en fazla 6 yazar, 4000 sözcük (kaynaklar, tablolar ve şekil alt yazıları dahil) 15 kaynak, 4 tablo ve/veya şekli içerir. Bu kısıtlamalardan başka, araştırma makalelerin tüm formatları, onay, etik ve yazım kılavuzları kısa raporlar için de geçerlidir.

Derleme Makalesi: Güncel ağrı uygulamasına ilişkin ulusal ve uluslararası literatürü gözden geçiren kapsamlı makalelerdir. Genellikle AĞRI Dergisi yalnızca davetli yazarların derleme makalelerini yayınlamaktadır. Diğer yazarlar derleme makalelerini göndermeden önce editörle iletişime geçmelidir. Derleme makalesi en fazla 2 yazarlı olmalı, kaynaklar, tablolar ve şekil altyazıları dahil 4000 sözcüğü geçmemelidir. Kaynakların sayısı sınırlandırılmamıştır.

Editöre Mektup: AĞRI Dergisi veya başka dergilerde yayınlanmış makalelere ilişkin düşünceler, yorumlar ve önerileri içerir. Mektuplar en fazla 1.000 sözcük içermelidir. Bu tek yazarlı yazılar için en fazla 5 kaynağın referans gösterilmesine izin verilir. Özet yazılması gerekmemektedir.

YAZAR KATKI VE İNSAN VE HAYVAN HAKLARI BİLDİRİMİ Bilimsel katkı ve sorumluluklar, ilgili herhangi bir finansal ya da çıkar çatışması varsa belirtilmelidir. Sorumlu yazar, çalışmanın ve yayının hazırlanmasına katkıda bulunan yazarların adlarını içeren formu imzaladıktan sonra yayıncıya göndermelidir. İnsan deneyleri rapor edilirken, yazarlar prosedürlerin 1975 Helsinki Deklerasyonu-2000, 2008 yılında revize edilen- uyarınca insan deneylerinden (kurumsal ve ulusal) sorumlu etik standartlara uygun olarak olup olmadığı belirtmelidir. Hayvanlar üzerindeki deneyler rapor edilirken, yazarlar laboratuvar hayvanlarının bakımı ve kullanımı için kurumsal ve ulusal rehberi uygulayıp uygulamadığını belirtmelidir. Lütfen makale ile ilgili detayları doldurduğunuz formun (Yazar Katkı ile İnsan ve Hayvan Hakları Bildirimi Formu) çıktısını alın ve formu imzaladıktan sonra faks veya elektronik olarak yayıncıya gönderin.

BİLGİLENDİRİLMİŞ ONAM BİLDİRİMİ Bilimsel amaç için gerekli olmadığı sürece, yazılı açıklamalarda, fotoğraflarda ve soy ağacında hastaların isimleri, baş harfleri veya hastane numaralarını içeren tanıtıcı bilgiler yayınlanmamalıdır ve hasta (ailesi ya da vasisi) yayınlanması için yazılı bilgilendirilmiş onam vermelidir. Bu amaç için bilgilendirilmiş onam, tanımlanabilir bir hastaya yayınlanacak makalenin gösterilmesini gerektirir. Yazarlar, yazıma destek sağlayan kişileri belirtmeli ve bu destek için fon kaynağını açıklamalıdır. Tanıtıcı detaylar eğer gerekli değil ise göz ardı edilmelidir. Lütfen makale ile ilgili detayları doldurduğunuz ve hasta veya yakınına formu imzalamalarını rica ettiğiniz formun (Bilgilendirilmiş Onam Bildirimi Formu) çıktısını alın, faks ile veya elektronik olarak yayıncıya gönderin.

TELİF HAKLARI VE ÇIKAR ÇATIŞMASI BİLDİRİMİ Yazarlar makalede bahsedilen materyal ile ilgili herhangi bir finansal kuruluş ile herhangi bir çıkar çatışması olmadığını belirtmelidir. Kabul edilen makaleler için, tüm yazarlar tarafından imzalanmış telif hakkı formu gönderilmelidir. Lütfen makale ile ilgili detayları doldurduğunuz formun (Telif Hakkı Devir Formu ve Çıkar Çatışması) çıktısını alın ve formu imzaladıktan sonra faks veya elektronik olarak yayıncıya gönderin.

YAYIN ÜCRETİ AĞRI erişme açık bir dergidir. Online olarak derginin web sayfasından yazılara ücretsiz olarak ulaşılmaktadır. Yayınlanan sunumlar için yazarlardan herhangi bir ücret talep edilmez.

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SCOPE AND PURPOSE This journal, which is published quarterly, is the official publicalion of Turkish Society of Algology, Reviews, details of interentional techniques, original researehes and case reports on the nature, mechanisms and treatment of pain are published. The journal provides a forum for the dissemination of research in the basic and clinical sciences of multidisciplinary interest. Opinions presented in published articles by no means represent the official endorsement of the Turkish Society of Algology. Articles and illustrations become the property of the Journal after publication.

INSTRUCTIONS FOR AUTHORS 1. The journal is published in Turkish and in English.

2. Manuscripts which are accepted by Editorial Board can be published. The Editorial Board have the right ro reject or to send the manuscript for review and revise. All manuscripts are subject to editing and, if necessary, will be returned to the authors for responses to outstanding questions or for addition of any missing information. For accuracy and clarity, a detailed manuscript editing is undertaken for all manuscripts accepted for publication.

Final galley proofs are sent to the authors for approval.

3. Articles not written according ro the 3rd editian (1983) of “common properties which are wanted in the articles that will be submitted to the Biomedical Journals” which was deternıined by the International Medical Journal Editorial Board, will not be accepted. Before submission it is adviced to look for these guidelines whieh are published in British Medical Journal 1988;296:401-5 or in Annals of Internal Medicine 1988;108:258-65.

4. All paper types are accepted via internet based manuscript processing system (www.journalagent.com/agri).

5. A paper which has not previously been published or being considered for publication elsewhere are accepted for publication. Papers which were published elsewhere previously as an abstract form may be published.

6. No payment for copyright of the article will be done. Therefore the letter accompanying the manuseript should include a statement that copyright of the article is transferred to the Turkish Society of Algology. The final manuscript should have been read and approved by the responsible authors.

7. If illustrations or other small parts of articles or books aIready published elsewhere are used in papers submitted to journal, the written permission of author and publisher corcerned must be included with the manuscript.

8. Authors should keep a copy of their manuscripts.

9. If a part or whole of a submitted manuscript will be published elsewhere, editor of the journal should be informed.

10. For researches, approvement of the institutional local ethics committee or its equivalent should be submitted.

11. All the responsibilities belong to authors.

12. No reprints will be sent to the author.

REQUIRED FILETYPES AND MINIMUM SUBMISSION REQUIREMENTS Before submission via electronic submission system, a number of separate MS Word (.doc) and Adobe (.pdf ) files should be prepared with the following formatting properties. No submissions will be accepted without a Cover Letter and a Title Page.

1. Cover Letter: A cover letter file should be included in all types of manuscript submissions. On the cover letter, the author(s) should present the title, manuscript type and manuscript category of the submission, and whether the submitted work had previously been presented in a scientific meeting.

The cover letter should contain a statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration by AGRI Journal. In addition, the full name of the corresponding author and his/her contact information including the address, phone number and e-mail address should be provided at the bottom of the cover letter. The cover letter should be signed by corresponding author, scanned and submitted in .jpg or .pdf format with other manuscript files. The order of a cover letter should be as follows: a. Title, manuscript type. b. Statement that the manuscript will not be published or evaluated for publication elsewhere while under consideration. c. Corresponding author(s) full name, contact information including address, phone, and e-mail address. d. Signature of the corresponding author.

2. Title Page: A title page file should be included in all types of manuscript submissions. Please prepare your title page as a separate electronic file, including the following elements: a. Title of the manuscript b. Author(s) list, please list their full names and up to 2 academic degrees per author; do not include honorary affiliations, such as fellow status in an organization. c. Affiliation(s) of each author, including department or division, institution, city, country. d. Corresponding author(s) full name, contact information including address, phone, and e-mail address. e. Funding or other financial support should be acknowledged. f. Conflict of interest statement: A conflict of interest statement should be provided in bottom of the title page. Please list of all potential conflicts of interest for each author, in accordance with ICMJE recommendations. In case of no conflicts of interests, please provide a statement such as: “Conflicts of Interest: None declared”.

3. Abstracts: On the abstracts page, the author(s) should present abstract and keywords (at least three) in this order. Turkish and English keywords should be chosen from Medical Subject Headings (MeSH) (http://www.nlm.nih.gov/mesh/MBrowser.html) and Türkiye Bilimler Terimleri (http://www. bilimterimleri.com).

4. Main Text: A main text file should be included in all types of manuscript submissions. This file should include title, abstracts page, main text of your manuscript, and the references section combined into a single electronic file. Tables can be included in this file as separate pages after References section, or may be uploaded separately as you prefer. Structure of the main text differs between manuscripts types. a. This combined file with the sections of abstracts, keywords, main text, references with/without tables should be a blinded version of the original manuscript. The names of the authors’, and any identifying information including the academic titles, institutions and addresses must be omitted. Apart from the stage of the manuscript evaluation process, manuscripts submitted with any information pertaining to the author(s) will be rejected as soon as it is noticed.

5. Tables: Tables summarizing the data should be clearly formatted without using any templates. Data presented in the tables should not be included in its entirety in the text. a. Tables must be numbered consecutively. b. Each table must be referred to in the text. c. Number and title of each table should be written at the top of each page before the table. d. Tables can be included in main text file as separate pages after references section, or may be uploaded separately as you prefer. If you prefer a separate file, tables should be uploaded in MS Word (.doc) format and the electronic file should be named accordingly (Tables_xxx_vx.doc). Tables should not be uploaded as pdf, jpeg or else.

6. Figures: If the manuscript includes figures then each figure should be uploaded as a separate file in all types of manuscript submissions. The information contained in the figure/image should not be repeated in its entirety, however reference to the figure/image must be referred in the text.

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a. i. ii. iii. iv. v.

Technical requirements Figure legends should appear on a separate page after the references section.

During submission, all figures must be uploaded in a separate file from the text file and should be named accordingly (Figure1_xxx; Figure2_xxx).

No legends or titles should be included in the figures.

Pictures should be saved in JPEG, EPS or TIFF format.

Please submit photographs and figures with a resolution of at least 300 dots per inch. Figures are easiest for us to process if submitted in TIFF or EPS format. b. Ethical requirements i. The owner and/or subject of the photograph must sign the patient consent form. ii. Figures should not be reproduced from other sources without permission 7. Statements, permissions, and signatures: a. Conflict of Interest Form: A conflict of interest exists when professional judgment concerning a primary interest (such as patients’ welfare or validity of research) may be influenced by a secondary interest (such as financial gain). Financial relationships are easily identifiable, but conflicts can also occur because of personal relationships or rivalries, academic competition, or intellectual beliefs. A conflict can be actual or potential, and full disclosure to The Editor is the safest course. Failure to disclose conflicts might lead to publication of an Erratum or even to retraction. All submissions to AGRI must include disclosure of all relationships that could be viewed as presenting a potential or actual conflict of interest. All authors are required to provide a conflict of interest statement and should complete a standard form. b. Patient Consent Form: Publication of any personal information about an identifiable living patient requires the explicit consent of the patient or guardian. We expect authors to use a standard patient consent form. c. Copyright Transfer Form: All authors are required to provide a copyright transfer from with complete a standard form.

MANUSCRIPT FORMATTING Manuscript format must be in accordance with the ICMJE-Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals(updated in August 2013). Papers that do not comply with the format of the Journal will be returned to the author for correction without further review. Therefore, to avoid loss of time and work, authors must carefully review the submission rules.

Manuscript structure should be complient with the guidelines of WAME. General Format 1. General Style: o The manuscript should be typed in a Microsoft Word™ file, single-column format, Every effort should be made to avoid medical jargon.

2. For the Blind Initial Review: The names of the authors’, and any identifying information including the academic titles, institutions and addresses must be omitted. Manuscripts submitted with any information pertaining to the author(s) will be rejected.

3. Drugs: Generic names for drugs should be used. Doses and routes for the drugs should be stated. When a drug, product, hardware, or software mentioned within the main text product information, including the name of the product, producer of the product, city of the company and the country of the company should be provided in parenthesis in the following format: “Discovery St PET/CT scanner (General Electric, Milwaukee, WI, USA)” 4. Abbreviations: We discourage the use of any but the most necessary of abbreviations. They may be a convenience for an author but are generally an impediment to easy comprehension for the reader. All abbreviations in the text must be defined the first time they are used (both in the abstract and the main text), and the abbreviations should be displayed in parentheses after the definition. Authors should avoid abbreviations in the title and abstract and limit their use in the main text.

5. Decimal points or commas: Decimal numbers should be separated from the integers with points. Commas should not be used in decimals throughout the manuscript.

6. References: References should be numbered consecutively in the order in which they are first mentioned in the text (6 authors then “et al”). Avoid referencing abstracts, or citing a “personal communication” unless it provides essential information not available from a public source. Examples of Referencing are as follows: o Article: Süleyman Ozyalçin N, Talu GK, Camlica H, Erdine S. Efficacy of coeliac plexus and splanchnic nerve blockades in body and tail located pancreatic cancer pain. Eur J Pain 2004;8:539-45. o Book: Newton ML. Current practice of pain. 1st ed. St. Luis, MO: Mosby; 1990. o Book Chapter: Turner JA. Coping and chronic pain. In: Bond MR, Charlton JE, Woolf CJ, editors. Pain research and clinical management. Proceedings of the VIth world congress on pain. Amsterdam: Elsevier; 1991. p. 219-27. o Courses and Lectures (unpublished): Erdine S. Pain. Course lecture presented at: International Pain Congress, June 7, 2008, İstanbul.

MANUSCRIPT TYPES AND SPECIFIC FORMATTING GUIDELINES Identification of article type is the first step of manuscript submission because article type dictates the guidelines that should be used, including formatting and word limits of the manuscript. The main categories are outlined below: Research Article: Original studies of basic or clinical investigations in algology. These articles can include randomized controlled trials, observational (cohort, case-control or cross-sectional) studies, destructive studies, diagnostic accuracy studies, systematic reviews and meta-analyses, nonrandomized behavioral and public health intervention trials, experimental animal trials, or any other clinical or experimental studies. Submission of research articles should include below mentioned pages, sections and files as defined above in required filetypes section: 1. Abstracts Page: Both English and Turkish (if relevant) abstracts are required. Abstracts should not exceed 250 words and should be structured with the following subheadings: Objectives, Material and Methods (with design), Results, and Conclusion (case control study, cross sectional study, cohort study, randomized controlled trial, diagnostic accuracy study, meta-analysis and systemic review, animal experimentation, non-randomized study in behavioral sciences and public health, etc.). In your results emphasize the magnitude of findings over test statistics, ideally including the size of effect and its confidence intervals for the principal outcomes.

2. Main Text: The main text should be structured with the following subheadings: Introduction, Material and Methods, Results, Discussion, Acknowledgments, References, Tables, and Figure Legends. a. Introduction: A three-paragraph structure should be used. Background information on study subject (1st paragraph), context and the implications of the study (2nd paragraph) and the hypotheses and the goals of the study (3rd paragraph). Background: Describe the circumstances or historical context that set the stage and led you to investigate the issue. Context: Describe why your investigation is consequential. What are its potential implications? How does it relate to issues raised in the first paragraph? Why is this specific investigation the next logical step? Goals of the study: Clearly state the specific research objective or hypothesis and your primary outcome measure. b. Material and Methods: The method section, is one of the most important sections in original research articles, and should contain sufficient detail. The

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investigation method, study sample, analyses performed, commercial statistical programs used, details of measurement and evaluation (e.g.: make and model of biochemical test devices and kits) should all be clearly stated. The names of local ethics committee or other approving bodies should be provided in Methods section for prospective studies. The Methods section should be organized with logical and sequential subheadings. c. Results: The demographic properties of the study population, the main and secondary results of the hypothesis testing must be provided. Commenting on the results and discussing the literature findings should be avoided in this section. Present as much data as possible at the level of the unit of analysis, graphically if possible. Emphasize the magnitude of findings over test statistics, ideally using size of effect and associated confidence intervals for each outcome. d. Discussion: The main and secondary results of the study should briefly presented and compared with similar findings in the literature. Providing intensive background information should be avoided in this section. Consider only those published articles directly relevant to interpreting your results and placing them in context. Do not stress statistical significance over clinical importance. Avoid extrapolation to populations or conditions that you have not explicitly studied in your investigation. Avoid claims about cost or economic benefit unless a formal cost-effectiveness analysis was presented in the Methods and Results sections. Do not suggest “more research is needed” without stating what the specific next step is. Optionally, you may include a paragraph “In retrospect, . . .” to candidly discuss what you would do differently if given the opportunity to repeat the study, so others can learn from your experience. e. Limitations: The limitations of the study should be mentioned in a separate paragraph subtitled as the “Limitations” in the end of the discussion. Explicitly discuss the limitations of your study, including threats to the internal and external validity of your results. When possible, examine the magnitude and direction of each bias and how it might affect the interpretation of results. f. Conclusion: A clear conclusion should be made in the light of the results of the study. The potential effects of the results of the study on the current clinical applications should be stated in a single sentence. Inferences that are not supported by the study results should be avoided. g. Acknowledgments: h. References: References section should be in a separate page. i. Figure Legends: Figure legends should be included in the main text in a separate page and this page should be the at the end of the main text file. j. Tables: At the end of the main text file as separate pages or as a separate file. k. Figures: Should not be included in the main text file and should be uploaded as separate files as with the properties describes above in required filetypes section: l. Ethics or Review Board Approval: If your manuscript involves original research, you will be asked to verify approval or exemption by an institutional review or ethics board. AGRI Journal will be unable to further consider manuscripts without approval or formal exemption. (The only exceptions are for analyses of third party anonymized databases which already have pre-existing IRB approval or exemption.)

Case Reports: Brief descriptions of clinical cases or the complications that are seldom encountered in algology practice and have an educational value.

Consideration will be given to articles presenting clinical conditions, clinical manifestations or complications previously undocumented in the existing literature and unreported side of adverse effects of the known treatment regimens or scientific findings that may trigger further research on the topic. Abstracts of case reports should mainly include information about the case, should not exceed 150 words, must be on a separate page and should be unstructured. The main text of Case Series should be structured with the following subheadings: Introduction, Case Presentations, Discussion and References.

Brief Report: Original reports of preliminary data and findings or studies with small numbers demonstrating the need for further investigation. Abstracts should not exceed 250 words and structured as research articles. Limitations include: maximum 6 authors, 4000 words (including references, tables, and figure legends), 15 references, 4 tables and/or figures. Besides these constraints, all the formatting, approval, ethics and writing guidelines of research articles also applies to brief reports.

Review Article: Comprehensive articles reviewing national and international literature related to current algology practice. Generally AGRI Journal publishes only invited review articles. Other authors should contact the editor prior to submission of review articles. Maximum 2 authors, 4000 words (including references, tables, and figure legends). There is no limit to the number of references.

Letter to the Editor: Opinions, comments and suggestions made concerning articles published in AGRI Journal or other journals. Letters should contain a maximum of 1,000 words and 5 references are allowed for these single author submissions. No abstract is required.

AUTHOR CONTRIBUTION & STATEMENT OF HUMAN AND ANIMAL RIGHTS Scientific contribution and responsibilities, any financial or other conflict of interest should be mentioned. Corresponding author should include the names of the authors who contributed to the preparation of the study and the manuscript and send to publisher after signing the form. When reporting experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 and 2008. When reporting experiments on animals, authors should be asked to indicate whether the institutional and national guide for the care and use of laboratory animals was followed. Please print out the form (Author Contribution & Statement of Human and Animal Rights Form) fill in the details about the article and sent to publisher by fax or electronic submitting system after signing the form.

STATEMENT OF INFORMED CONSENT Patients have a right to privacy that should not be infringed without informed consent. Identifying information, including patients’ names, initials, or hospital numbers, should not be published in written descriptions, photographs, and pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed consent for publication. Informed consent for this purpose requires that a patient who is identifiable be shown the manuscript to be published. Authors should identify Individuals who provide writing assistance and disclose the funding source for this assistance. Identifying details should be omitted if they are not essential. Please print out the form (Statement of Informed Consent Form), fill in the details about the article, ask the patient or next of kin to sign the form, and sent to publisher by fax or electronic submitting system after signing the form.

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x

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İ Ç İ N D E K İ L E R C O N T E N T S 2020-3 v viii

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Yazarlara Bilgi Information for the Authors

KLİNİK VE DENEYSEL ÇALIŞMALAR ORIGINAL AND EXPERIMENTAL ARTICLES 115–119 Patient-controlled analgesia and morphine consumption in sickle cell anemia painful crises:

A new protocol

Orak hücre anemisi ağrılı krizlerinde hasta kontrollü analjezi ile morfin tüketimi: Yeni bir protokol

Bakır M, Rumeli Atıcı Ş, Yıldırım HU, Tiftik EN, Ünal S 120–127 Effects of working years in cold environment on the musculoskeletal system and carpal

tunnel symptoms

Soğuk ortamda çalışma yıllarının kas iskelet sistemi ve karpal tünel sendromu semptomları

üzerine etkisi

Altuntaş YD, Çankaya T 128–139 Can conscious guilt feelings incite nocebo pain?

Suçluluk duyguları nosebo ağrı tepkilerini güçlendirebilir mi?

Türkarslan KK, Çınarbaş DC 140–146 A comparison of the ultrasound-guided modified-thoracolumbar interfascial plane block and

wound infiltration for postoperative pain management in lumbar spinal surgery patients

Lomber spinal cerrahi yapılan hastalarda postoperatif analjezi yönetimi için ultrason eşliğinde yapılan

modifiye-torakolomber interfasiyal plan bloğu ve yara yeri infiltrasyonunun karşılaştırılması:

Prospektif, randomize çalışma

Ekinci M, Çiftçi B, Çelik EC, Yayık AM, Tahta A, Atalay YO 147–151 Telephone versus self administration of outcome measures in low back pain patients

Bel ağrılı hastalarda değerlendirme ölçütlerinin telefon veya kendi kendine uygulanmasının karşılaştırılması

Şencan S, Çelenlioğlu AE, Kokar S, Ulutatar F, Karadağ Saygı NE 152–158 Ultrasound detection of sciatic nerve movements with ankle dorsiflexion/plantar flexion:

Prospective comparative study of a novel method to locate the sciatic nerve

Siyatik sinir hareketinin ayak bileği dorsifleksiyon ve plantar fleksiyonuyla ultrason eşliğinde

görüntülenmesi: Siyatik sinirin yerinin belirlenmesinde yeni bir yöntem

Balaban O, Yaman M, Aydın T, Musmul A

OLGU SUNUMLARI CASE REPORTS 159–161

162–163

164–167

168–170

171–174

Frontal recess osteoma causing severe headache Şiddetli başağrısına neden olan frontal reses osteomu Aksakal C Erişkin hemofili hastasında ultrason rehberliğinde penil blok ile cerrahi anestezi Surgical anesthesia using ultrasound-guided penile nerve block for adult hemophilia patient Cesur S, Gürkan Y, Türkyılmaz N, Kuş A, Aksu C Fluoroscopically guided transforaminal epidural catheterization of the ankylosing spondylitis Ankilozan spondilitli olguda floroskopi eşliğinde transforaminal epidural kateter Şanal Baş S, Güleç SM Rejyonel anestezide nadir görülen unutulması durumunda yüksek risk taşıyan bir refleks: Bezold-Jarisch refleksi Rare reflex in regional anesthesia which have a high-risk in case of forgotten: Bezold-Jarisch reflex Akyol F, Binici O, Özmen Ö, Büyükfırat E, Erol K, Karahan MA Tolosa-Hunt Sendromu; kliniği, kranyal MR özellikleri ve tedavisi Tolosa-Hunt Syndrome; clinical and brain MRI features and treatment Ali A, Yalçın R

EDİTÖRE MEKTUPLAR LETTER TO THE EDITORS 175–176 A new treatment modality in piriformis syndrome: Ultrasound guided dry needling treatment

Piriformis sendromunda yeni bir tedavi modalitesi: Ultrason rehberliğinde kuru iğneleme tedavisi

Bağcıer F, Tufanoğlu FH

TEMMUZ - JULY 2020

v

Agri 2020;32(3):115–119

doi: 10.14744/agri.2020.46354

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ORIGINAL ARTICLE

Patient-controlled analgesia and morphine consumption in sickle cell anemia painful crises: A new protocol Orak hücre anemisi ağrılı krizlerinde hasta kontrollü analjezi ile morfin tüketimi: Yeni bir protokol Mesut BAKIR,1

Şebnem RUMELI ATICI,1

Hüseyin Utku YILDIRIM,2

Eyüp Naci TIFTIK,3

Selma ÜNAL4

Summary Objectives: The sudden and rapidly increasing severity of pain in sickle cell anemia painful crises frequently requires the use of strong opioids. Patients require continuous administrations of various doses (increased/decreased) within the following hours. This study aims to retrospectively evaluate the effects of a structured protocol based on standardized Visual Analogue Scale (VAS) and Patient-controlled analgesia (PCA) patient demand count on morphine consumption in painful crises.

Methods: A total of 177 painful crises of 93 patients who were administered morphine using the PCA method according to appropriate analgesia protocol between 2004–2018 were evaluated in this study. The demographic data, hemoglobin chromatography and genotypes, painful episode follow-up time, VAS scores before and after treatment, and daily morphine consumption of the patients were recorded. Morphine consumption during the crisis according to age groups and sex were compared.

Results: Of the patients, 57% were homozygous hemoglobin type SS (HbSS). Mean morphine consumption with PCA method was 56.9±35.4 mg (min-max: 10–232 mg) and mean follow-up time was 3.4±2.1 days (min.–max.: 1–11). VAS scores were significantly lower after treatment (6.8±2.3 pre-treatment; 0.8±0.6 post-treatment) (p<0.05).

Conclusion: To our knowledge, our study is the first structured protocol based on VAS and PCA demand data. We believe lower morphine dosage using PCA protocol according to the rapidly changing pain levels of the patients will provide effective analgesia. Prospective studies with fewer limitations will more effectively demonstrate the effectiveness of this protocol.

Keywords: Analgesia protocol; morphine; painful crises; patient controlled analgesia; sickle cell anemia.

Özet Amaç: Orak hücreli aneminin ağrılı krizlerinde ağrının ani gelişen ve hızla yükselen şiddeti, sıklıkla güçlü opioid kullanımı gerektirmektedir. Bununla birlikte hastalar saatler içerisinde sürekli farklı doz (arttırma/azaltma) uygulamalarına ihtiyaç duymaktadırlar. Bu çalışma ile retrospektif olarak, ağrılı krizlerde, standardizasyonu görsel ağrı skalası (VAS) ve hasta kontrollü analjezi yöntemindeki (HKA) hasta istek sayısına göre yapılandırılmış bir protokolün, morfin tüketimi üzerine etkisinin değerlendirilmesi amaçlandı.

Gereç ve Yöntem: 2004–2018 yılları arasında, analjezisi için protokole uygun olarak, HKA yöntemi ile morfin uygulanan, 93 hastanın 177 ağrılı krizi incelendi. Hastaların demografik verileri, hemoglobin kromotografileri ve genotipleri, ağrılı dönem takip süresi, tedavi öncesi ve sonrası VAS değerleri, günlük morfin tüketimleri kaydedildi. Yaş grupları ve cinslere göre ağrılı kriz dönemi morfin tüketimleri karşılaştırıldı.

Bulgular: Hastaların %57’sinin homozigot tip olan Hb SS olduğu görüldü. HKA yöntemi ile ortalama morfin tüketimi 56.9±35.4 mg (en düşük-en yüksek/10 mg–232 mg), ortalama takip süresi 3.4±2.1 gün (en düşük-en yüksek/1–11) idi. Hastaların VAS değerleri, tedavi öncesine göre tedavi sonrasında istatistiksel olarak düşük bulundu (sırasıyla, 6.8±2.3, 0.8±0.6) (p<0.05).

Sonuç: Bu çalışmamız, VAS ve HKA istek verilerine göre yapılandırılmış ilk protokoldür. Hastaların hızla değişen ağrı düzeylerine göre programlanan HKA protokolümüz ile daha düşük düzeylerde morfin kullanılarak etkin analjezinin sağlanabildiği kanısındayız. Limitasyonların azaltılabileceği prospektif çalışmalarla protokolün etkinliğinin daha net ortaya konabileceğini düşünmekteyiz.

Anahtar sözcükler: Analjezi protokolü; morfin; ağrılı kriz; hasta kontrollü analjezi; orak hücreli anemi.

Department of Algology, Mersin University Faculty of Medicine, Mersin, Turkey Department of Algology, Antalya Training and Research Hospital, Antalya, Turkey 3 Department of Hematology, Mersin University Faculty of Medicine, Mersin, Turkey 4 Department of Pediatric Hematology, Mersin University Faculty of Medicine, Mersin, Turkey 1 2

Submitted (Başvuru tarihi) 02.09.2019 Accepted after revision (Düzeltme sonrası kabul tarihi) 13.01.2020 Available online date (Online yayımlanma tarihi) 05.05.2020

Correspondence: Dr. Şebnem Rumeli Atıcı. Mersin Üniversitesi Tıp Fakültesi, Algoloji Kliniği, 33130 Çiftlikköy, Yenişehir, Mersin, Turkey.

Phone: +90 - 506 - 333 77 33 e-mail: sebnematici@hotmail.com © 2020 Turkish Society of Algology

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Introduction Sickle-cell anemia (SCA) is a common life-threatening hematologic disease that affects millions of people throughout the world.[1] Approximately 305.800 newborns were born with SCA in the year 2010 and this number is estimated to rise to 404.200 by the year 2050.[2] Painful crises are the main cause of hospitalizations in these patients (over 90%). Crises are defined as the clinical condition that occurs with acute ischemic changes in tissues, as a result of sickled erythrocytes adhering to endothelium and preventing microcirculation.[3–5] The acute and increasingly severe character of the pain often requires use of strong analgesics. Quality of life is severely impaired during this period.[6] It has been reported that 37% of patients hospitalized due to painful crises have experienced three or more recurrent crises within a year.[7] While the acute and increasing severity of the painful episodes in SCA patients often require use of strong opioids, continuous changes in dosage (increase/ decrease) are needed within hours, depending on the efficacy of non-analgesic treatment.[8,9] Therefore, opioids are administered on an as-needed basis for analgesia in painful crises.[10,11] Most clinicians prefer opioid administration with basal infusion and patient-controlled analgesia (PCA) method programmed with demand doses.[12] The PCA method has also been found to be effective by health personnel and parents in pediatric patients diagnosed with SCA.[13] There is no widely accepted standardized protocol for analgesic treatment of painful crises.[14] Studies have shown that the PCA method has lower opioid consumption, only compared to continuous infusion method.[15] Furthermore, there are only few studies in the literature on establishing PCA protocol for treatment of SCA painful crises.[15,16] While the American National Health Institute guidelines published in 2014, and the England National Health Service guidelines published in 2012 and updated in 2016 have recommended steps for painful crises treatment, a flowchart for PCA programming has not been determined.[17,18] The Hematology and Algology departments of our hospital use a structured analgesia protocol based 116

on standardized Visual Analogue Scale (VAS) and patient demand of the PCA method for treatment of painful crises since 2004. Our study aims to evaluate the morphine consumption of patients administered analgesia under this protocol.

Material and Methods By obtaining ethics committee approval, records of 132 patients over 18 years of age, diagnosed with SCA and hospitalized due to painful crises between the years 2004–2018 were evaluated. The 39 patients who were not administered morphine using the PCA method were excluded from the study. The 233 painful crises of the remaining 93 patients who were included in the study were assessed. Fifty-six painful crises were determined to have been treated with a combination of various opioids along with morphine, and were excluded from the study.

The demographic data, follow-up period for each crisis, VAS scores before and after treatment, and daily morphine consumption of the 177 patients with painful crises were recorded from algology follow-up records. The morphine consumption and hospitalization length during painful crisis period were compared according to age groups and sex.

The hemoglobin subgroups, genotypes, hemogram values, and hydroxyurea administrations of the patients were recorded. Patients diagnosed with acute chest syndrome at least once during hospitalization and mean number of yearly painful crises were also recorded.

Analgesia protocol of painful crises The Hematology and Algology departments of our hospital have followed a protocol for treatment of painful crises since 2004 (Fig. 1). According to this protocol: patients with VAS ≥4 despite intravenous (IV) paracetamol 4x1000 mg and peroral (po) ibuprofen 3x800 mg undergo consultation by the algology department. During the initial evaluation, IV bolus morphine 1 mg and, if necessary, IV 0.5 mg morphine at five-minute intervals are administered for reduced to below VAS 4. At the same time, PCA IV morphine infusion is initiated (infusion: 1 mg/s + bolus dose: 1 mg; lockout interval: 15 min). Patients are evaluated bedside at least twice daily at 08.00–16.00. When demand number is <6 at evaluation, dosage is adjusted to 0.5 mg/0.5 mg/15 min. When demand count is less than 6, infusion is stopped (0.5 mg/15 min).

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Paracetamol 4x1000 mg iv + ibuprofen 3x800 mg po

VAS≥4

Morphine iv bolus VAS<4

PCA 1 mg/1 mg/15 min.

Demand<6 PCA 0.5 mg/0.5 mg/ 15 min.

Demand<6 PCA 0.5 mg/15 min.

Demand<6 STOP

Table 1. Hemoglobin genotypes and chromatography Hemoglobin genotype SS (n, %) SB (n, %) Chromatography HbA HbA2 HbF HbS Hemoglobin (gr/dL)

53 (57) 40 (43) Mean 7.3±11.0 4.0±1.0 9.1±5.3 76.6±10.1 8.4±1.1

Min.–Max. (0–39) (0.9–7.7) (0.0–22.3) (40.1–94.2) (5.7–11.4)

Min.: Minimum; Max.: Maximum.

Figure 1. PCA analgesia protocol of painful crises.

Table 2. Patient follow-up and analgesic data

VAS: Visual analogue scale; PCA: Pacient controlled analgesia.

When demand count is less than six during followup, PCA is discontinued. The patient continues to receive paracetamol and ibuprofen during the rest of the period.

Statistical analysis For statistical analysis, the “Statistical Package for the Social Sciences version 22 (SPSS v.22)” program and the “e-PICOS” program was used for calculations based on “MedicReS Good Biostatistical Practice”.

Descriptive statistics was used for categorical variables and frequency calculations were expressed as percentage. Chi-square test was used for crosstabulations. Independent group t-test and dependent group t-test were used for comparison of mean values. The value p<0.05 was considered statistically significant.

Results Follow-up periods of 177 painful crises of 93 patients were investigated. Fifty-two percent of the patients were male (M/F: 48/45). Mean age was 28.53±8.5 years (mean–max: 18–61). As for hemoglobin genotypes, 57% of patients were homozygous type HbSS. According to patient chromatography, while the major prognostic factor of HbF levels were 9.1%±5.3, HbS levels were 76.6%±10.1. Mean hemoglobin level before painful crisis was 8.4±1.1 gr/dL (range: 5.7–11.4) (Table 1). Acute chest syndrome was diagnosed in 50.6% (n=47) of the patients. Regular hydroxyurea use was observed in 82% (n=76) of the patients. Mean number of yearly painful crises was 3.2±2.8/year (range: 1–12).

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Mean Min.–Max.

Follow-up length per crisis (days) Total morphine consumption per crisis (mg) Mean number of yearly painful crises

3.43±2.1

1–11

56.9±35.4

10–232

3.2± 2.8

1–12

Min.: Minimum; Max.: Maximum.

Table 3. Distribution of follow-up length and morphine consumption according to age groups and sex

Sex Female Male Age groups (years) 18–23 24–29 30–61

Follow-up Morphine (days) consumption (mg) 3.86±2.3 3.51±1.9

56.1±30.1 57.6±40.1

3.6±1.7 3.7±2.4 3.6±2.1

54.7±30.9 61.8±41.3 55.1±35.2

Mean follow-up time of hospitalized patients under PCA protocol was 3.4±2.1 days (range: 1–11) (Table 2). Mean morphine consumption during painful crisis period was 56.9±35.4 mg (10–232 mg). Highest IV bolus morphine dose administered upon hospital admittance was 12 mg. There was no significant difference in morphine consumption or crisis follow-up period according to age groups or sex (p>0.05) (Table 3).

While mean VAS scores before PCA method morphine treatment was 6.8±2.3, these scores decreased to 0.8±0.6 after treatment (Fig. 2).

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VAS scores

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6.8

Pre-treatment

0.8 Post-treatment

Figure 2. VAS scores before and after morphine administration with PCA. p<0.05.

Discussion Our study includes the first analgesia protocol that dynamically manages rapidly changing pain according to VAS scores and PCA demand in painful crises.

It is also the most comprehensive study to evaluate morphine consumption with the PCA method using a standard protocol in SCA painful crises. The protocol demonstrates that effective analgesia can be achieved with low morphine dosage.

The literature states that age, genotype, hydroxyurea use, HbF levels, and presence of acute chest syndrome are all important factors in the severity of painful crises. According to age, the highest incidence is between ages 18–30.[19] In our study, mean age was 28.53±8.5. Tyagi et al.[20] reported that painful crises were more frequent in HbSS genotype patients (62.5%) compared to HbSB patients, but was not statistically significant. Serjeant et al.[21] indicated that HbSS and HbSB were the most significant patient genotypes. In our study, the most significant genotypes were HbSS (57%) and Hb SB (43%). Pahl et al.[22] evaluated 109 patients and observed that 50% of HbSS and HbSB genotype patients were diagnosed with acute chest syndrome (ACS) at least once during hospitalization due to painful crisis. In our patients, 50.6% were diagnosed with ACS during painful crisis. Hydroxyurea treatment was shown to reduce the frequency of painful crises by increasing HbF levels and reducing production of adhesion molecules.[23–25] While patients with high HbF levels experience milder painful crises, they are more severe in patients with lower levels.[26,27] Although 82% of our patients were receiving hydroxyurea treatment, their HbF levels (9.1%±5.3) were consistent with the severe painful form. According to the results of the study, it was concluded that the patients possessed serious risk factors for painful crises.

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In a meta-analysis by Ballas et al.,[3] it was reported that severe painful crises lasted on average of 9–11 days, with the most painful period starting on the third day, and pain decreasing on the sixth-seventh day. In our study, we observed that the mean followup period of painful crises managed with the PCA method was 3.4±2.1 days. The mean follow-up period of our patients was similar to the established painful crisis cycle.

Al-Anazi et al.[28] compared intermittent IV administration and PCA method in SCA painful crises in a retrospecitve study. It was reported that, with PCA method, mean morphine consumption of the patients within 72 hours was 777±175 mg. The mean morphine consumption with PCA method in our study (56.9±35.4) was relatively lower than other studies that evaluated morphine consumption in painful crises. Van Beers et al.[15] compared morphine consumption of PCA and continuous infusion methods in SCA patients with painful crises. The aforementioned study found morphine consumption was lower with PCA method compared to continuous infusion (PCA: 33 mg; continuous infusion: 260 mg). Although the low dosage was reported in the PCA group, the lowest mean VAS scores was over 4. We believe these VAS scores are insufficient to be considered as effective analgesia. In our study, VAS scores before treatment (6.8±2.3) were consistent with the literature, however, the fact that our VAS scores after treatment (0.8±0.6) were relatively lower suggests that our PCA protocol for analgesia is substantially effective.

The retrospective nature was a limitation of our study. However, application of a standard protocol for treatment and twice daily evaluation of the patients reduces this limitation. The lack of satisfaction scores of the patients after treatment, using patient satisfaction scales, was another limitation of our study. The fact that pain scores were recorded twice a day using VAS scale, and that patients had active participation in analgesia in the scope of the protocol reduces this limitation.

Conclusion Our study is the first structured protocol according to VAS and PCA demand numbers. We believe that lower doses of morphine using programmed PCA protocol according to the rapidly changing pain levels of patients can provide effective analgesia. The JULY 2020

A new protocol of painful crises in sca

effectiveness of the protocol would be clarified with prospective studies with reduced limitations.

Ethics Committee Approval: The Mersin University Human Research Ethics Review Board granted approval for this study (date: 12.07.2018, number: 78017789/050.01.04/E.786416).

Author Contributions: Mesut Bakır, Şebnem Rumeli Atıcı and Hüseyin Utku Yıldırım performed the research, Mesut Bakır and Şebnem Rumeli Atıcı designed the research study and analysed the data, Mesut Bakır, Şebnem Rumeli Atıcı, Naci Tiftik and Selma Ünal wrote the paper.

Conflict-of-interest issues regarding the authorship or article: None declared.

Peer-rewiew: Externally peer-reviewed.

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2. Piel FB, Patil AP, Howes RE, Nyangiri OA, Gething PW, Dewi M, et al. Global epidemiology of sickle haemoglobin in neonates: a contemporary geostatistical model-based map and population estimates. Lancet 2013;381(9861):142–51.

3. Ballas SK. Pain management of sickle cell disease. Hematol Oncol Clin North Am 2005;19(5):785–802.

4. Ballas SK, Gupta K, Adams-Graves P. Sickle cell pain: a critical reappraisal. Blood 2012;120(18):3647–56.

5. Dampier CD, Smith WR, Wager CG, Kim HY, Bell MC, Miller ST, et al; Sickle Cell Disease Clinical Research Network (SCDCRN). IMPROVE trial: a randomized controlled trial of patient-controlled analgesia for sickle cell painful episodes: rationale, design challenges, initial experience, and recommendations for future studies. Clin Trials 2013;10(2):319–31.

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search Network (SCDCRN). Inpatient management of sickle cell pain: a ‘snapshot’ of current practice. Am J Hematol 2012;87(3):333–6.

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15. van Beers EJ, van Tuijn CF, Nieuwkerk PT, Friederich PW, Vranken JH, Biemond BJ. Patient-controlled analgesia versus continuous infusion of morphine during vaso-occlusive crisis in sickle cell disease, a randomized controlled trial. Am J Hematol 2007;82(11):955–60.

16. Dampier CD, Smith WR, Kim HY, Wager CG, Bell MC, Minniti CP, et al; Investigators of the Sickle Cell Disease Clinical Research Network (SCDCRN). Opioid patient controlled analgesia use during the initial experience with the IMPROVE PCA trial: a phase III analgesic trial for hospitalized sickle cell patients with painful episodes. Am J Hematol 2011;86(12):E70–3.

17. Buchanan GR, Yawn BP. Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014. Available at: https://www.nhlbi.nih.gov/sites/default/files/media/docs/ sickle-cell-disease-report%20020816_0.pdf.

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20. Tyagi S, Choudhry VP, Saxena R. Subclassification of HbS syndrome: is it necessary? Clin Lab Haematol 2003;25(6):377–81.

21. Serjeant GR. The natural history of sickle cell disease. Cold Spring Harb Perspect Med 2013;3(10):a011783.

22. Pahl K, Mullen CA. Original Research: Acute chest syndrome in sickle cell disease: Effect of genotype and asthma. Exp Biol Med (Maywood) 2016;241(7):745–58.

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24. Mozeleski BM, Al-Rubaish A, Al-Ali A, Romero J. Perspective: A Novel Prognostic for Sickle Cell Disease. Saudi J Med Med Sci 2018;6(3):133–6.

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26. Habara AH, Shaikho EM, Steinberg MH. Fetal hemoglobin in sickle cell anemia: The Arab-Indian haplotype and new therapeutic agents. Am J Hematol 2017;92(11):1233–42.

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28. Al-Anazi A, Al-Swaidan L, Al-Ammari M, Al-Debasi T, Alkatheri AM, Al-Harbi S, et al. Assessment of patient-controlled analgesia versus intermittent opioid therapy to manage sickle-cell disease vaso-occlusive crisis in adult patients.

Saudi J Anaesth 2017;11(4):437–41.

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ORIGINAL ARTICLE

Effects of working years in cold environment on the musculoskeletal system and carpal tunnel symptoms Soğuk ortamda çalışma yıllarının kas iskelet sistemi ve karpal tünel sendromu semptomları üzerine etkisi Yasin Devran ALTUNTAŞ,

Tamer ÇANKAYA

Summary Objectives: Musculoskeletal disorders are the most common work-related health problems. The risk of musculoskeletal disorders is increased by working in a cold environment. The present study aims to investigate the effects of working years on the body.

Methods: We examined the effects of the working years on the musculoskeletal system and carpal tunnel syndrome symptoms of the individuals who were engaged in cutting, shredding, packaging, bagging and transportation operations at 9 degrees and lower ambient temperatures in a poultry factory in Turkey. Nordic Musculoskeletal Questionnaire (NMQ) was used to evaluate musculoskeletal symptoms of the individuals. Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) was used to investigate the carpal tunnel symptoms. Individuals grouped according to their total working years in a cold factory setting.

Groups were formed as less than two years, between two and five years, between six and nine years, and ten years or more.

Results: This study showed that the increase in working years in a cold factory setting might lead to a feeling of pain and discomfort in various regions of the body, disrupt ordinary works due to the pain felt (p<0.05). This study also showed that the severity of the symptoms felt because carpal tunnel syndrome worsened, especially when an individual has been working for more than ten years in cold.

Conclusion: Working in the cold for a long time may result in long-term health effects on the human body.

Keywords: Cold temperature; cumulative trauma disorders; discomfort; pain; poultry sector.

Özet Amaç: İşle ilgili sağlık sorunları arasında en yaygın olanı kas-iskelet sistemi hastalıklarıdır. Soğuk bir ortamda çalışmak kasiskelet sistemi rahatsızlıkları riskini arttırmaktadır. Bu çalışmanın amacı, soğuk ortamda çalışma yıllarının vücut üzerindeki etkilerini araştırmaktı.

Gereç ve Yöntem: Çalışma yıllarının Türkiye’deki bir fabrikada 9 derece ve altında kanatlı hayvanlarda kesme, parçalama, paketleme, torbalama ve taşıma işlemleri yapan ve düşük ortam sıcaklıklarında çalışan bireylerin kas-iskelet sistemi ve karpal tünel sendromu semptomları üzerindeki etkisini inceledik. Bireylerin kas iskelet sistemi semptomlarını değerlendirmek için İskandinav Kas İskelet Sistemi Sorgusu kullanıldı. Karpal tünel semptomlarını araştırmak için Boston Karpal Tünel Sendromu Anketi kullanıldı. Bireyler toplam çalışma yıllarına göre gruplandırılmışlardır. Gruplar iki yıldan az, iki ila beş yıl, altı ila dokuz yıl ve on yıl veya daha fazla olarak kuruldu.

Bulgular: Bu çalışma soğuk bir fabrika ortamında çalışma yıllarındaki artışın, vücudun çeşitli bölgelerinde ağrı ve rahatsızlık hissinde artışa yol açabileceğini, hissedilen ağrı nedeniyle sıradan işlerin etkilenebileceğini göstermiştir (p<0,05). Ayrıca bu çalışma, karpal tünel sendromu nedeniyle hissedilen semptomların ciddiyetinin, özellikle on yıldan fazla bir süre soğukta çalışıldığında kötüleştiğini göstermiştir.

Sonuç: Uzun süre soğukta çalışmak, insan vücudunda sağlık problemlerine neden olmaktadır.

Anahtar sözcükler: Soğuk; kümülatif travma bozuklukları; rahatsızlık; ağrı; kanatlı hayvan sektörü.

Introduction Musculoskeletal disorders are the most common work-related health problems. Generally, manual work, heavy physical work, working in inappropriate

and static postures, continuous repetition of movements and vibration are the main factors that cause these disorders. Occupational disabilities and disorders are an important issue in developing countries,

Department of Physical Therapy and Rehabilitation, Bolu Abant İzzet Baysal University, Bolu, Turkey Submitted (Başvuru tarihi) 17.06.2019 Accepted after revision (Düzeltme sonrası kabul tarihi) 29.01.2020 Available online date (Online yayımlanma tarihi) 05.05.2020

Correspondence: Dr. Yasin Devran Altuntaş. Bolu Abant İzzet Baysal Üniversitesi, Kemal Demir Fizik Tedavi ve Rehabilitasyon Yüksekokulu, Gölköy Kampüsü, 14030 Bolu, Turkey.

Phone: +90 - 506 - 821 89 56 e-mail: ydaltuntas@gmail.com © 2020 Turkish Society of Algology

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Effect of working years in cold environment on musculoskeletal system and carpal tunnel symptoms

which account for 70% of the global workforce. Recent evaluations show that job-related health loss causes significant losses in total national production percentages.[1] Most of the musculoskeletal disorders associated with work are cumulative, occurring in the long term by repeating low or high-intensity loads. Symptoms vary from discomfort and pain to reduced body function and disability. The extent to which these diseases originate from work life is not clear, but the effects on daily life are shown.[2] It can also interfere with activities that need to be done at work, reduce production, cause workers to obtain sick leave and increase chronic occupational insufficiency.[3] Carpal tunnel syndrome (CTS) is a neuromuscular condition caused by compression neuropathy and constitutes 90% of all nerve compressions.[4] Commonly reported CTS symptoms include wrist and hand pain, paresthesia, muscle weakness and loss of dexterity.[5–7] Female gender, increased age, physical illness, repetitive hand use, and occupation are potential risk factors for CTS development.[4,7] In many cross-sectional studies, low environmental temperature and routine work have been shown to increase the risk of musculoskeletal disorders.[8–10] It is accepted that the risk of CTS is high in professions where meat and fish were processed.[8,11,12] Although the cold has been shown to adversely affect various parameters of muscle performance, such as strength, speed, and coordination, few studies have investigated the effects of cold on body functions.[13] This study aimed to investigate the effects of working years on the musculoskeletal system and especially on carpal tunnel syndrome symptoms.

Material and Methods This study included 568 individuals who were engaged in cutting, shredding, packaging, bagging and transportation operations at 9 degrees and lower ambient temperatures in a poultry factory. Evaluations were made at the factory where the individuals worked. After the assessment forms were distributed to the workers, necessary explanations were made about the participation and questionnaires. Inclusion criteria were to work in a cold environment at least 9 JULY 2020

degrees Celsius in the factory, to be able to understand and respond to survey, to be between the ages of 18–60, and to be a volunteer. The exclusion criteria were to be diagnosed with rheumatic disease, to have undergone surgery due to an orthopedic disorder, to have a history of trauma that still affects the person physically, and to receive treatment due to a discomfort requiring physical therapy. This descriptive study approved by Abant İzzet Baysal University Clinical Research and Ethics Committee, (Decision No. 121 on 26/05/2017. Resolution NO: 2017/37).

765 people were tested for convenience. 178 people were excluded from the study because they did not work in cold conditions and had a history of orthopedic surgery and 9 people refused to participate. During the study, 568 individuals were included in the evaluation criteria. Of those working in cold conditions, 506 were working at 5 degrees and below, and 62 at 9 degrees. Ambient temperature was measured by the factory measuring system. The individuals included in the study were informed about the study and their consent was obtained. Individuals grouped as less than 2 years (n=211), 2–4 years (n=140), 5–9 years (n=147) and 10 years or more (n=70) according to working years in cold.

Nordic Musculoskeletal Questionnaire Symptoms of the musculoskeletal system were evaluated using the Nordic Musculoskeletal Questionnaire (NMQ) developed in 1987.[14] Kahraman et al.[15] adapted the NMQ to the Turkish language in 2016.

The questionnaire has two parts. In the first part; name, surname, date of evaluation, gender, date of birth, how many years and months the current work was done, the average number of hours worked in a week, the weight, height and the dominant side were questioned. The second part is supported by a body map image to indicate that nine symptoms (neck, shoulder, back, elbow, waist circumference, wrist/hand, hip/thighs, knees and ankles/feet) are present. The participant can see the approximate positions of the body parts mentioned in the body diagramme of the questionnaire. The question of whether there are any problems (pain, discomfort) in the aforementioned 9 regions, whether or not a normal job (at home or outside the home) is caused by pain, and whether there is any pain during the last 7 days or not, is one of the questions in the format of yes/no in the questionnaire format.[15] 121

A RI PAIN Table 1. Distribution of gender, dominant extremity and smoking status of working year groups

Sex Female Male Dominant extremity Right Left Smoking status Yes No

Less than 2 years (n=211) n

2–5 years 5–10 years Over 10 years (n=140) (n=147) (n=70) n n n

Total χ²

p

123 88

77 63

89 61

33 37

319 1.112 0.376 249

192 19

129 11

129 18

62 8

512 1.940 0.585 56

88 123

56 84

52 95

28 42

224 1.499 0.683 344

χ²: Chi-square test; n: Number of individuals; p>0.05.

Boston Carpal Tunnel Syndrome Questionnaire Symptoms of Carpal Tunnel Syndrome were evaluated using the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). The BCTQ developed by Levine et al.[16] in 1993, later adapted to Turkish by Sezgin et al.[17] in 2006. BCTQ consists of two parts. The first part is called the Symptom Severity Scale (SSS). It has 11 questions. Questions the symptoms related to carpal tunnel syndrome. The second part, the Functional State Scale (FSS), reveals the level of difficulty experienced in the 8 activities designed. Scoring is generally calculated in 1–5 for each question and the increase in score indicates worsening of symptoms.[17] Demographic Questionnaire The questionnaire examined gender, date of birth, daily working hours in cold, working days in a week, body weight, length, dominant extremity, presence of chronic disease, use of painkillers, the level of pain felt while resting and working.

Statistical Analysis The minimum number of individuals required for each group found as 67 by using the G*Power program with the settings of α<0.05 β=%80 power. Descriptive statistical methods used for demographic information. The chi-square test was used to compare NMQ scores to the work years. Since there was an equal distribution in the evaluation, the Anova test was used for comparing the groups’ BCTQ scores. For the post-hoc analysis, the Bonferroni test was used.

The statistical significance level of the data taken as p<0.05. SPSS 22 program was used for the analysis.

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Results Distribution of gender, dominant extremity and smoking status of working year groups The mean age of the patients was 36,92±8,61 years, the mean weight was 71,47±13,10 kg, the mean height was 165,35±8,83 cm, body mass index was 26,12±4,23 kg/m2.

319 (56.1%) of the participants were female and 249 (43.9%) were male. 512 (90.3%) of the individuals were right-handed and 56 (9.7%) were left-handed. There was a normal distribution in the gender, dominant extremity and smoking between groups (Table 1) (p>0.05).

Comparison between NMQ scores of working years groups The effect of the cold working years on the scores of the NMQ was investigated. Answers for “Have you at any time during the last twelve months had trouble (such as ache, pain, discomfort, numbness)?”shown a significant difference between groups for hip and knee regions. Answers for“Have you at any time during the last twelve months been prevented from doing your daily activities (at home or away from home) because of the trouble?” shown significant difference between groups for hip and elbow regions. Answers for “Have you had trouble at any time during the last seven days?” question shown significant difference shoulder region (p<0.05). No significant change was observed for all three questions in other regions (p>0.05) (Tables 2, 3).

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Effect of working years in cold environment on musculoskeletal system and carpal tunnel symptoms

Table 2. Comparison between NMQ scores and working years of the neck and upper extremities

Neck A Yes No Neck B Yes No Neck C Yes No Shoulders A Yes No Shoulders B Yes No Shoulders C Yes No Elbows A Yes No Elbows B Yes No Elbows C Yes No Wrists/hands A Yes No Wrists/hands B Yes No Wrists/hands C Yes No

Less than 2 years (n=211) n

2–5 years (n=140) n

5–10 years (n=147) n

Over 10 years (n=70) n

χ²

p

140 71

88 52

94 53

38 32

186 25

124 16

123 24

54 6.667 0.083 16

149 62

101 39

106 41

42 3.993 0.262 20

130 81

79 61

86 61

38 1.599 0.660 32

182 29

124 16

129 18

55 4.402 0.221 15

148 63

98 42

114 33

40 9.533 30

181 30

114 26

121 26

54 3.091 0.378 16

197 14

135 5

140 7

60 9.900 10

184 27

128 12

128 19

56 5.534 0.137 14

111 100

71 69

80 67

27 5.234 0.115 43

170 41

120 20

122 25

52 4.426 0.219 18

134 77

104 36

105 42

45 25

3.333 0.343

0.023

0.019

5.742 0.125

χ²: Chi-square test; A: Have you at any time during the last 12 months had trouble (ache, pain, discomfort)?; B: Have you at any time during the last 12 months been prevented from doing your normal work (at home or away from home) because of the trouble?; C: Have you had trouble at any time during the last 7 days? p<0.05.

Comparison between the BCTQ scores of working years groups The effect of individuals’ working years on the results of Boston carpal tunnel syndrome was examined. There JULY 2020

was no statistical difference between the work year groups in the Boston FSS score (p=0.577), but it was found that Boston SSS (p=0.008) scores get higher as individual’s working years increase (p<0.05) (Table 4).

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A RI PAIN Table 3. Comparison between NMQ scores and working years of the spine and lower extremities

Upper back A Yes No Upper back B Yes No Upper back C Yes No Low back A Yes No Low back B Yes No Low back C Yes No Hips/tights A Yes No Hips/tights B Yes No Hips/tights C Yes No Knees A Yes No Knees B Yes No Knees C Yes No Ankles/feet A Yes No Ankles/ feet B Yes No Ankles/feet C Yes No

Less than 2 years (n=211) n

2–5 years (n=140) n

5–10 years (n=147) n

Over 10 years (n=70) n

χ²

p

134 77

76 64

89 58

38 3.830 0.280 32

183 28

121 19

128 19

54 4.607 0.203 16

141 70

104 36

112 35

47 4.958 0.175 23

115 96

62 78

75 72

29 5.595 0.133 41

174 37

111 29

121 26

51 3.556 0.314 19

136 72

98 42

105 42

41 4.224 0.238 29

191 20

122 18

120 27

53 11.817 17

0.008

202 9

133 7

137 10

58 14.882 12

0.002

190 21

127 13

135 12

57 6.043 0.110 13

154 57

96 44

90 57

34 15.629 36

192 19

123 17

129 18

56 6.058 0.109 14

167 44

111 29

115 32

49 2.884 0.410 21

119 92

85 55

82 65

31 5.165 0.160 39

176 35

124 16

119 28

53 6.200 0.102 17

144 67

101 39

104 43

42 28

0.001

3.546 0.315

χ²: Chi-square test; A: Have you at any time during the last 12 months had trouble (ache, pain, discomfort)?; B: Have you at any time during the last 12 months been prevented from doing your normal work (at home or away from home) because of the trouble?; C: Have you had trouble at any time during the last 7 days? p<0.05.

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Effect of working years in cold environment on musculoskeletal system and carpal tunnel symptoms

Table 4. Comparison between the BCTQ scores (functional status scale and symptoms severity scale) of working years groups

Boston FSS Boston SSS

Less than 2 years (n=211) X±SD 1.30±0.62 1.74±0.80

2–5 years 5–10 years Over 10 years (n=140) (n=147) (n=70) X±SD 1.38±0.81 1.70±0.89

1.39±0.75 1.74±0.74

1.41±0.78 2.11±1.18

f 0.660 3.968

df 564 564

p 0.577 0.008

f: One way anova; df: Degree of freedom; X: Average value; SD: Standard deviation; FSS: Functional state scale; p<0.05.

Table 5. Post-hoc evaluations of Boston SSS scores for working year groups

Working years

Less than 2

2–5 years Boston SSS

5–10 years

Over 10 years

Working years

Mean

SD

p

2–5 years 5–10 years Over 10 years Less than 2 5–10 years Over 10 years Less than 2 2–5 years Over 10 years Less than 2 2–5 years 5–10 years

0.04127 0.00048 -0.36718 -0.04127 -0.04079 -0.40844 -0.00048 0.04079 -0.36766 0.36718 0.40844 0.36766

0.09469 0.09332 0.11982 0.09469 0.10258 0.12716 0.09332 0.10258 0.12615 0.11982 0.12716 0.12615

1.000 1.000 0.014 1.000 1.000 0.008 1.000 1.000 0.022 0.014 0.008 0.022

F: One way anova post hoc Bonferoni; SD: Standard deviation; p<0.05.

Post-hoc evaluations of Boston SSS scores Post-hoc evaluations of the Boston SSS scores according to their working years are the work year was more than ten years, there was a statistically significant difference in scores compared to all other groups (p<0.05) (Table 5).

Discussion Exposure to cold in the work environment may be due to cold weather/wind exposure, dipping into water or touching cold surfaces. According to standard guidelines and norms, cold work can be defined as a situation of cold or cold feeling in a working environment. Even in a light physical job with an ambient temperature below 10 degrees can create this sensation. According to other international standards, cold work is generally defined for jobs with an ambient temperature below 10–15 degrees.[18] It is found that the pain felt on the shoulder in the last 7 days was related to the working years. Shoulder is a JULY 2020

joint where the problems are common in the works where active use of the upper extremity is required.

In cold conditions, these muscles cannot work properly, causing muscular pain and injury. Decrease in muscle temperature adversely affects all parameters such as endurance, power, speed, and coordination of muscle performance.[19] The decrease in the performance of hypothermic skeletal muscle can also be attributed to a decrease in nerve conduction velocity.[20,21] Muscle function and co-ordination also deteriorate due to the suppression of agonist muscle activity and increased antagonist muscle activity in hypothermic muscle.[21,22] Fatigue occurs earlier with these changes and repetitive activities when muscle temperature falls.[21,23] These effects prepare the ground for overuse injuries.[24] When muscle temperature drops, muscle spindle activity, and motor neuron activity decrease, therefore muscle tension reflex decreases. This prevents the muscle from releasing sufficient force.[13] It is re125

A RI PAIN ported that the working year and the working hours were effective on shoulder problems in cashiers.[25] In this study, the increase in the working year and the disruption of the ordinary works due to pain felt in the elbow in the last 12 mounts were found to be correlated. The elbow is an active joint in meat processing and packaging activities. Therefore it is susceptible to injuries and disabilities.

The incidence of epicondylitis was reported to be 11.3% in female sausage makers, 7% in female packers and 6.4% in male meat cutters. The temperature of the environment where the sausages are working is 20 degrees and the temperature of the women working in the package is 8â&#x20AC;&#x201C;10 degrees. The incidence of these diseases is reported to be less than 1% in non-demanding workers.[8] In this study, the problems experienced in the knee and hip in the last 12 months (pain, discomfort) and the disruption of the ordinary works due to the pain felt in the hip in the last 12 months were found to be related. In our opinion, there are 2 possible causes of pain in the hips and knees. The first is the effect of low ambient temperature on muscle performance.

Secondly, it can be defined as muscular pain due to long term standing. It is reported that individuals exposed to severe cold (-10, -25 degrees) have been reported to have more musculoskeletal pain than those exposed to moderate cold (-5, 5 degrees) and MDs developed in individuals as a result of cumulative exposure to cold work environment and waist and knee symptoms were very common in individuals exposed to cold for 5 years or more.[26] It has been proven that long term repetitive hand and wrist movements, uncomfortable hand placement and position, continuous pressure on wrist or hand are related to Carpal Tunnel Syndrome and complaints about Carpal Tunnel Syndrome are seen more frequently in people who carry out activities involving such risks.[27,28] Participants were exposed to several of these factors at the same time. These factors can be counted as cold, continuous and long term hand-wrist activities and continuous pressure due to cutting action. We think that the continuous work of our participants increased the risk of microtraumas. Moreover, the slowing of the nerve conduction speed and the decrease of muscle performance due to cold are also effective factors.[20, 21] 126

Our study has four main limitations. Firstly, employees could not be grouped according to their professions because there were many different jobs in the factory setting. Secondly, jobs were not normally distributed for gender groups. Women were mostly employed in cutting and packaging, where more men working in storage areas. Thirdly, tests used to diagnose carpal tunnel syndrome could not be used due to work intensity and lack of time. Fourthly, the absence of a control group of individuals who did not work in a cold environment made a possibly meaningful comparison impossible. Therefore, increased musculoskeletal problems may be due to the cold environment or increased years of work. Considering the shortcomings of this study, some suggestions can be given for further studies. The physical difficulty of the work performed and the postures taken to do the work can be properly classified.

Nerve conduction tests for carpal tunnel syndrome can be included in the study. Working in populations where genders can normally be distributed can lead to more objective results.

Conclusions The results of this study demonstrated that the increase in working years in a cold factory setting may lead to a feeling of pain and discomfort in various regions of the body, disrupt ordinary works due to the pain felt and worsen the symptoms for carpal tunnel syndrome. There was a correlation between the increased working year and the pain felt on the shoulder in the last 7 days was found. There was a correlation between the increasing work years and the disruption of the ordinary works due to the pain felt in the elbow and the hip. The problems (pain, discomfort) felt on the knees and hips in the last 12 months were related to the increasing work years.

It was concluded that the increase in working years worsened the symptoms of carpal tunnel syndrome.

Participants exhibited a worse picture both functionally and symptomatically.

Ethics Committee Approval: This descriptive study approved by Abant Ä°zzet Baysal University Clinical Research and Ethics Committee, (Decision No. 121 on 26/05/2017. Resolution NO: 2017/37).

Conflict-of-interest issues regarding the authorship or article: None declared.

Peer-rewiew: Externally peer-reviewed.

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Effect of working years in cold environment on musculoskeletal system and carpal tunnel symptoms

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Agri 2020;32(3):128–139

doi: 10.14744/agri.2020.99710

A RI PAIN

ORIGINAL ARTICLE

Can conscious guilt feelings incite nocebo pain?

Suçluluk duyguları nosebo ağrı tepkilerini güçlendirebilir mi?

Kutlu Kağan TÜRKARSLAN,

Deniz Canel ÇINARBAŞ

Summary Objectives: Psychodynamically, chronic pain problems with no organic cause have been conceptualized as a punishment through physical pain for guilt feelings. This study aimed to investigate the effects of conscious guilt feelings on nocebo pain responses and whether the resultant nocebo pain would affect conscious guilt feelings in the form of expiation through the pain.

Methods: An experiment was conducted with 100 participants. There were two independent variables, which were guilt induction (guilt-no guilt) and nocebo manipulation (nocebo-no nocebo). Nocebo manipulation was done by telling the participants that they would receive electricity from an EEG cap. In addition, they watched a video in which a confederate imitates having pain during the procedure. There were two dependent variables, guilt feelings, and experienced pain. Guilt feelings were measured using Positive and Negative Affect Scale twice, once after guilt induction and once after nocebo pain manipulation. Subjective pain scores were measured by using a basic 0 to 10 visual pain scale, on which the participants reported how much pain they experienced.

Results: The findings revealed that only the main effect of nocebo was significant.

Conclusion: The participants reported mild headaches in the absence of any physical stimulation after nocebo manipulations. The effect was observed in a standard laboratory environment. Non-physical nocebo pain induction could create pain, but conscious guilt induction did not increase the amount of reported nocebo pain, and resultant pain did not function as a punishment. Limitations and implications of the study were discussed.

Keywords: Expectation; guilt; headache; nocebo effect; punishment.

Özet Amaç: Organik sebepleri tespit edilemeyen kronik ağrı problemleri psikodinamik literatürde, kişinin fiziksel ağrıyı kullanarak hissettiği suçluluk duyguları sebebiyle kendisini cezalandırması orası olarak kavramsallaştırılmıştır. Bu çalışmanın amaçları bilinçli suçluluk duygularının nocebo ağrılarının oluşumu üzerindeki etkilerinin ve ortaya çıkan nocebo ağrılarının bilinçli suçluluk duyguları üzerindeki etkisinin incelemektir.

Gereç ve Yöntem: Bu çalışmada deney 100 katılımcı ile yürütülmüştür. Çalışmanın suçluluk uyandırılması ve nocebo manipülasyonu olmak üzere iki bağımsız değişkeni vardır. Nocebo manipülasyonu katılımcılara başlarında taktıkları bir EEG şapkasından kendilerine elektrik verileceğinin söylenmesi ve ağrı çekiyormuş gibi taklit yapan bir katılımcının bu prosedürü gerçekleştirirken ki videosunun izletilmesiyle yapılmıştır. Çalışmanın bağımlı değişkenleri suçluluk duyguları ve nocebo manipülasyonu sonrası deneyimlenen ağrıdır. Suçluluk duygularını Pozitif ve Negatif Duygu Ölçeği kullanılarak ilk olarak suçluluk uyandırılması sonrası, daha sonra nocebo manipülasyonu sonrası iki kere ölçülmüştür. Suçluluk duyguları katılımcılara ne kadar ağrı hissettiklerini 0 ile 10 arasında göstermelerini isteyen basit görsel bir ölçekle ölçülmüştür.

Bulgular: Yapılan analizler sonucu sadece nocebo değişkeninin ana etkisi anlamlı bulunmuştur.

Sonuç: Katılımcılar herhangi bir fiziksel uyarıma maruz kalmadan hafif baş ağrısı deneyimlediklerini rapor etmişlerdir. Bu etki standart bir laboratuvar ortamında gözlemlenmiştir. Bilinçli suçluluk duygularının hissedilen nocebo ağrısını üzerinde anlamlı bir etkisi olmadığı bulunmuştur. Ayrıca ortaya çıkan nocebo ağrısı bir cezalandırma işlevi gördüğünü hipotezi de desteklenememiştir. Çalışmanın kısıtlılıkları ve implikasyonları tartışılmıştır.

Anahtar sözcükler: Beklenti; suçluluk; baş ağrısı; nocebo etkisi; cezlandırma.

The article was generated from the master thesis that the first author produced in supervision of the second author.

Department of Psychology, Middle East Technical University, Ankara, Turkey Submitted (Başvuru tarihi) 11.06.2019 Accepted after revision (Düzeltme sonrası kabul tarihi) 13.01.2020 Available online date (Online yayımlanma tarihi) 04.05.2020

Correspondence: PhD Stu. Kutlu Kağan Türkarslan. Orta Doğu Teknik Üniversitesi, Psikoloji Bölümü, 06800 Ankara, Turkey.

Phone: +90 - 312 - 210 51 10 e-mail: kutlu.turkarslan@metu.edu.tr © 2020 Turkish Society of Algology

128

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Can conscious guilt feelings incite nocebo pain?

Introduction Chronic pain can be regarded as a widespread health problem. Percentages of people suffering from chronic pain range between 11% and 63.7%, depending on the population investigated and the methodology used.[1–6] Unfortunately, chronic pain problems propose a challenge for physicians, especially in the absence of clear and discernible organic causes.[7] For example, 80% of back pain problems lacks clear organic diagnosis.[8] Furthermore, studies with follow up assessment revealed that if no underlying organic cause is found as a result of the initial assessment, it is extremely unlikely finding one latter in time.[9] Therefore, in many cases of chronic pain problems, the practitioners assume that there may be an undiscovered and underlying physio-pathological process producing pain, or that the pain is caused by psychological factors.[10] Consequently, even though researchers investigated a long list of risk factors for pain, they have failed to find a prominent physical and psychosocial variable that can adequately explain chronic pain problems.

[11] The concept of nocebo pain may shed light on the experience of pain in the absence of organic causes.

When individuals expect to experience pain, they indeed may feel pain. In addition, from psychodynamic perspective, it can be asserted that guilt feelings may find a way of expiation through the pain. The purpose of the present study was to investigate the interaction of nocebo pain and guilt feelings.

The concept of nocebo has not been as popular as its sibling, placebo. Concisely, it can be defined as the worsening or occurrence of a symptom in expectation of a negative outcome.[12] In medical terms, it involves a non-pharmacodynamic, noxious, unpleasant, and generally undesirable effect experienced by the person getting an inactive treatment.

[13] Acknowledging nocebo effect is a crucial attempt to deepen the understanding of patients’ pain experiences. Because, people may have pain without any sensory stimulation or they may experience a nonnoxious stimulus as painful, due to nocebo effects.

For example, in a pioneering study, Schweiger and Parducci[14] told college students that a mild electric current would be given to their heads through an JULY 2020

EEG cap, while doing a task to reduce possible headaches. There was no real electrical stimulation, but two-thirds of 34 students reported mild headaches.

In another study by Johansen, Brox, and Flaten,[15] the participants’ pain reports increased after injection of a saline solution, which was believed by the participants to be a pain exacerbating solution. Colloca, Sigaudo, and Benedetti[16] were able to turn a nonpainful tactile stimulus into a painful one, and lowintensity pain into high-intensity pain with verbal suggestions or conditioning. Moreover, Vögtle, Barke, and Kröner-Herwig[17] showed that even observational learning might play on a role in nocebo responses.

In observational learning condition, the participants were shown a video of a model expressing more pain with the application of an ointment increasing pain and the participants’ pain ratings were higher with ointment than without. In control and verbal suggestion conditions, the pain ratings were similar, independent of the application of the ointment.

Interestingly, Jensen et al.[18] conducted two experiments consisting thermal pain stimulus conditioned with two male faces showing that nocebo effect is evident when conditioned stimuli are presented both consciously (100 ms) and unconsciously (stimuli for 12 ms, followed by a visual mask for 84 ms).

The participants responded to low pain temperature with high cue as if it was high pain temperature. As demonstrated by the results of a meta-analysis involving ten studies, the nocebo effect is found to have a moderate to large effect size (lowest g=0.62 [0.24–1.01] and highest g=1.03 [0.63–1.43]).[19] Underlying biological and neurological mechanisms producing nocebo reactions have been widely studied. Several studies have stressed the role of cholecystokinin in nocebo hyperalgesia through anticipatory anxiety mechanisms.[20,21] Keltner et al.[22] examined the effects of two types of expectancy (high and low) on noxious stimulus via fMRI and found that the ipsilateral caudal, anterior cingulate cortex, the head of the caudate, cerebellum, and the contralateral nucleus cuneiformis were activated distinctly.

In anticipation of pain, different levels of activation were spotted at insula,[23] the anterior cingulate cortex, the ventromedial prefrontal cortex, and the periaqueductal grey.[24] To sum up, the nocebo effect is an important concept having real consequences on 129

A RI PAIN the experience of pain. Expectation and anticipatory anxiety are regarded as the main motivators of nocebo pain responses. Apart from these motivators, psychodynamic perspective suggests that physical pain may provide a way of expiation from the guilt feelings by using pain as a punishment.

With children, it is easy to observe that they are often ‘naughty’ on purpose to provoke punishment, and are quiet and content after they have been punished. Later analytic investigation can often put us on the track of the guilty feeling, which induced them to seek punishment.[30]

Psychodynamic approach has conceptualized roles of shame and guilt in psychopathology more elaborately than other theoretical approaches.[25] Since the publication of Studies of Hysteria,[26] many psychodynamic hypotheses have been proposed about the role of psychological conflicts in the occurrence of some somatic complains, including chronic pain.

Sigmund Freud was one of the pioneer thinkers who dealt with guilt feelings and their psychic and behavioral consequences.[27] One of his first mentions of guilt can be found in his work entitled “The defense neuro-psychoses”.[28] He discussed symptoms of an obsessive girl who became extremely doubtful that she actually did the bad acts that she read in the newspaper. Even though she acknowledged the absurdity of such obsessions; in time, she began to believe that she did them in real life. Later, in the analysis, Freud traced the causes of these absurd guilty feelings to the girl’s sexual relationship with a woman involving masturbation for several years.

Here, the guilt can be understood as a strong motivator underlying obsessional symptoms’ formation.

According to Freud, a more systematic conceptualization of guilt comes after the emergence of the superego. In terms of intrapsychic conflicts, guilt becomes a tool for superego to modulate ego.[31] Superego is a societal agent comprising cultural norms and values; in other words, the representative of civilization within. In “Civilization and Its Discontents,” Freud remarked the conflict between humans and civilization and role of guilt in this sense:

Freud thought that guilt could disguise itself in the form of illness or physical symptoms. In his seminal paper, The Ego and The Id, he further contemplated the relationship between guilt and illness:

To begin with, if we ask how a person comes to have a sense of guilt, we arrive at an answer which cannot be disputed: a person feels guilty (devout people would say ‘sinful’) when he has done something which he knows to be ‘bad.’ But then we notice how little this answer tells us. Perhaps, after some hesitation, we shall add that even when a person has not actually done the bad thing but has only recognized in himself an intention to do it, he may regard himself as guilty; and the question then arises of why the intention is regarded as equal to the deed.[33]

We finally come to realize that what is involved here is a ‘moral’ factor, so to speak: a guilt-feeling that finds its gratification in illness and refuses to forgo the punishment that suffering represents. Although this explanation is scarcely cheering, it is one that merits our unwavering support. However, this guiltfeeling remains entirely mute vis-à-vis the patient: it does not tell him he is guilty, and instead of feeling guilty, he feels ill.[29] Moreover, Freud asserted that people try to get rid of guilt feelings by seeking punishment, and this is apparent in childhood. In his essay, “Some CharacterTypes Met with in Psycho-Analytic Work”, he wrote: 130

The tension between the harsh superego and the ego that is subjected to it, is called by us the sense of guilt; it expresses itself as a need for punishment.

Civilization, therefore, obtains mastery over the individual’s dangerous desire for aggression by weakening and disarming it and by setting up an agency within him to watch over it, like a garrison in a conquered city.[32] Yet, do we feel guilty only when we do something wrong? Freud was dissatisfied with a simple yes answer to this question, and he stated:

In summary, Freud was one of the first thinkers to acknowledge that guilt feelings can lead to somatic and non-somatic symptoms in the form of punishment. His ideas later inspired other psychoanalytic scholars such as George L. Engel who theorized about the relationship between chronic pain, psychic conflicts, and object relations. Treating pain JULY 2020

Can conscious guilt feelings incite nocebo pain?

as a sensory phenomenon, Engel asserted that it might be possible to experience pain without direct sensory stimulation. He[9] presumed that a person collects a library of pain experiences resulting from peripheral pain stimulations during his or her course of life. Like visual or auditory experiences, they may be activated without any direct sensory stimulation. He proposed several personal meanings of pain experiences by connecting them to development and psyche.

First, pain is a part of our protection system and warns us about possible damage or loss of body parts.[9] Therefore, when pain emerges, it is important to learn and record what is causing pain in that environment and the body parts affected by the pain. The cause and location of pain are the main components of pain memories or the bodyâ&#x20AC;&#x2122;s pain image. Second, pain is entangled with interpersonal relationships. Because of pain, an infant cries to get help from his or her significant other. Therefore, an association between pain, crying, the soothing response of significant other, and relief of pain may be established. Third, during early childhood, pain and punishment are strongly linked to each other. Pain is generally induced as a form of punishment for childrenâ&#x20AC;&#x2122;s guilty deeds. Therefore, pain signals that one is bad or guilty, and sometimes a need for expiation through pain may be needed. He stated: I mention this component first because clinical observation leads me to conclude that guilt, conscious or unconscious, is an invariable factor in the choice of pain as the symptom, as compared to other types of body sensations. Clinically we should expect to find either a long-term background of guilt and an immediate guilt-provoking situation precipitating pain.[9] Several scientific studies supported the existence of the link between guilt and the need for punishment as proposed by Engel. For example, participants who wrote about their unethical behaviors of rejecting or ostracizing another person, both held their hand in cold water longer (longer pain duration) and rated their experience as more painful than participants in the control group.[32] Moreover, their guilt feelings were significantly reduced after experiencing the pain. In another study, Nelissen[33] reported that participants administered higher level electrical shocks JULY 2020

to themselves when they were with someone whom they felt guilty about.

Therefore, it can be asserted that initiation of psychogenic pain or transformation of acute physical pain into chronic pain may be a way of expiation for conscious and unconscious guilt as suggested by psychodynamic theorists.[9,25,34] Stated differently, guilty feelings may exacerbate pain responses, and in return, pain may alleviate guilt feelings. Previous research focused on the relationship between chronic pain and various variables, such as psychopathology or dominant affective states such as anger, anxiety, and depression.[35â&#x20AC;&#x201C;37] Due to the non-experimental nature of previous studies, it is not possible to determine a robust causal relation between affective variables and chronic pain problems, even if clinical observation frequently suggests such links. Therefore, examining the effects of guilt on psychogenic pain experiences and effects of pain experience on guilt feelings, using experimental design may contribute to the theoretical understanding of the relationship between guilt and pain.

The aim of the present study was to test whether conscious guilt feelings can increase the likelihood of reporting pain and severity of subjective pain reports in a non-physical nocebo manipulation and whether conscious guilt feelings alleviate after experiencing nocebo pain. It was hypothesized that non-physical nocebo manipulation would conceive pain, and those who wrote guilt-inducing memories would report more pain compared to those who wrote neutral memories. It was also hypothesized that the guilt feelings of the participants who experienced nocebo pain would be less than guilt feelings of the participant who did not experience pain.

Nocebo pain induction was selected to evoke pain because it was found in previous studies that it can produce psychogenic pain sensation without any noxious stimulation.

Material and Methods Participants The study sample was comprised of 100 students from Middle East Technical University who were invited to participate in the study via departmental online subject pool system. In return for their participation, they received bonus points for their cours131

A RI PAIN Table 1. Table showing four conditions of the study

Nocebo manipulation

Guilt induction

No guilt induction

n=25 n=25

n=25 n=25

Nocebo manipulation No nocebo manipulation

es. There were 78 female (78%) and 22 male (22%) participants with ages ranging between 18 and 33 (M=21.67, SD=1.92). Seventy four of the participants (74%) were psychology undergraduate students and 26 of the participants (26%) were undergraduates from various departments at Middle East Technical University.

Design The design of the study was 2x2 independent groups design. There were two independent variables (guilt and nocebo), two dependent variables (pain ratings and pre-post manipulation guilt scores). Each of the four experimental groups had 25 participants (Table 1). The participants were assigned to four conditions by their registration order in the SONA system.

Procedure The study was approved by the Research Center for Applied Middle East Technical University. The participants were met by the experimenter, and they were asked to fill out informed consent and demographics forms. In the informed consent form, the participants were told that the study is about the effects of pain and memory on hand-eye coordination. Afterward, they were asked to write about either a memory that involves guilt or a neutral memory consisting of their daily interactions with other people. Then, Positive and Negative Affect Scale[38,39] was given for manipulation check. The sixth item of PANAS measures guilt feelings on a 1 to 5 scale (1=not at all, 5=extremely).

Participants in the nocebo group received visual, verbal, and video instructions about getting mild electric current from the EEG cap. Multiple methods, such as visual and video instructions were used together to strengthen the effect of manipulation.

First, they were shown a visual statement on the computer. Then, they received a verbal statement from the experimenters that the EGG cap would give mild electric current to their head. Finally, they 132

Guilt induction

watched a video in which a confederate with EEG cap appeared to be having pain during the procedure. On the other hand, no nocebo group received only a neutral statement that the EEG cap measures brain waves, and there were no instructions involving electricity being given. Later, the participants were asked to complete a visual task[40] while wearing an EEG cap, to keep them occupied during pain induction. In the task, the participants were asked to estimate the location of a circle moving from the top of the screen to the bottom of it. When the circle reaches half way through the screen, the circle becomes invisible behind a blue wall. The blue wall has another grey circle. The participants decide when the circle will fit exactly to the grey circle by clicking a button. After completing the visual task, the participants were asked to rate how much pain they felt during the procedure on a 0 to 10 scale (0=no pain at all, 10=unendurable pain). If they reported pain on the scale (any response different from 0), they were verbally asked about the type, location, and description of the pain experience.

Afterward, PANAS forms were given again to check whether guilt scores changed after pain manipulation. Finally, the participants received a debriefing form partially explaining the aim of the study as measuring the effects of guilt, feelings and physical pain on pain perception. At this time, the participants were not informed that the EEG cap did not actually induce electricity, in order to prevent them from sharing this information with prospective participants. Once all the data were collected, the participants were contacted via e-mail and provided with a complete explanation of the studyâ&#x20AC;&#x2122;s procedures.

Results The data were analyzed with JASP 0.9.2 and SPSS 24.

There were no missing values for any of the dependent variables. No multiple outliers were detected.

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Can conscious guilt feelings incite nocebo pain?

Table 2. Descriptives for interaction of guilt and nocebo conditions on square root of pain ratings Guilt No

Yes

Nocebo

Mean

No Yes No Yes

SE

Lower CI

0.566 0.142 1.075 0.142 0.588 0.142 0.776 0.142

Upper CI

0.284 0.793 0.306 0.494

n

0.848 1.356 0.870 1.058

25 25 25 25

SE: Standard error; CI: Confidence interval.

Table 3. The results of ANOVA for effects of guilt and nocebo conditions on square root of pain ratings Cases Guilt Nocebo Guilt*Nocebo Residual

Sum of squares

df

Mean square

0.478 1 0.478 3.027 1 3.027 0.642 1 0.642 48.415 96 0.504

F

p

η²p

0.948 0.333 0.010 6.003 0.016 0.059 1.274 0.262 0.013

ANOVA: Analysis of variance.

Manipulation check for guilt induction In order to check whether guilt induction through writing memories had an effect on guilt scores, an independent t-test was conducted between guilt and no guilt conditions. It was found that guilt scores were significantly higher for the participants who wrote guilt-inducing experiences (M=3.520, SD=1.129) than for the participants who wrote daily interaction experiences (M=1.560, SD=1.072), t(98)=-8.901, p<0.001, 95% CI [-2.397, -1.523]. This represented a very strong effect, d=-1.780. The guilt manipulation had a significant effect on participants’ guilt ratings.

Manipulation check for nocebo induction To test whether non-physical nocebo induction had an effect on pain ratings, an independent t-test was conducted on nocebo and no nocebo conditions of pain ratings. It was found that pain ratings were JULY 2020

1.4

Nocebo No Yes

Pain scores

Shapiro-Wilk Test of Normality indicated significant deviation from normality (W=0.769, p<0.001). Pain ratings across all groups were distributed non-normally with a kurtosis of 3.518 (SE=0.241), and skewness of 1.656 (SE=0.478). Therefore, square root transformation was conducted on the pain ratings.

[41,42] The square root transformation yielded better skewness values than logarithmic transformation.

Presented data were not back transformed, because there were only slight range differences between non-transformed and transformed values.

0.2 No

Guilt

Yes

Figure 1. Pain ratings as a function of nocebo and guilt condition.

significantly higher for the participants who were exposed to nocebo manipulation (M=0.925, SD=0.717) than for the participants who were not exposed to nocebo manipulation (M=0.577, SD=0.705), t(98)=2.446, p=0.016, 95% CI [-0.629, -0.066]. This represented a moderate effect, d=-0.489. The nocebo manipulation had a significant effect on pain ratings of the participants.

The effects of nocebo and guilt on pain ratings It was hypothesized that the participants who were in the nocebo condition would report higher levels of pain compared to those in the no-nocebo condition and participants who were asked to write a past guilt-inducing experience would report higher levels of pain in nocebo condition compared to those participants who were asked to write about a neutral 133

A RI PAIN Table 4. Descriptives for interaction between time and nocebo conditions Time Pre

Post

Nocebo

Mean

No Yes No Yes

SE

Lower CI

3.600 0.228 3.440 0.228 2.280 0.208 2.120 0.208

Upper CI

3.142 2.982 1.863 1.703

n

4.058 3.898 2.697 2.537

25 25 25 25

SE: Standard error; CI: Confidence interval.

Table 5. The results of repeated measures ANOVA for main effect of time and interaction of time and nocebo

Time Time*Nocebo Residual

Sum of squares

df

Mean square

43.560 1 43.560 4.333e -32 1 4.333e -32 25.440 48 0.530

F

p

η²p

82.189 <0.001 0.631 8.176e -32 1.000 0.000

ANOVA: Analysis of variance.

Table 6. The results of ANOVA for main effect of nocebo

Nocebo Residual

Sum of squares

df

Mean square

F

p

η²p

0.640 1 0.640 0.348 0.558 0.007 88.400 48 1.842

ANOVA: Analysis of variance.

4.0

Nocebo No Yes

Guilt scores

experience. Two (Nocebo, No-Nocebo) by two (Guilt, No-Guilt) independent groups ANOVA was conducted to examine the interaction. Only the main effect of nocebo was significant, F (1, 96)=6.003, p=0.016, ηρ²=0.0059 (Table 2, 3). There was no significant interaction between guilt and nocebo, and the participants in the guilt induction condition did not have higher pain ratings compared to participants in no guilt condition (Fig. 1).

1.5 Pre

The effects of nocebo and time on guilt feelings It was hypothesized that guilt feelings of the participants who were asked to write a past guilt-inducing experience would decrease after having nocebo pain. In other words, there would be an interaction between time and nocebo, no-nocebo conditions on guilt scores. Two (Nocebo, No-Nocebo) by two (Pre nocebo manipulation guilt scores, Post nocebo manipulation guilt scores) mixed ANOVA with repeated measures on the last factor was conducted. Only the main effect of time was significant, F (1, 48)=82.189, p<0.001, ηρ²=0.631 (Table 4–6). There was no significant interaction effect and the participants who 134

Guilt time

Post

Figure 2. Guilt scores as a function of time and nocebo.

wrote guilt-inducing memories in the nocebo induction condition did not have lower guilt scores than those in the no-nocebo condition (Fig. 2).

Discussion The results revealed that participants in the nocebo condition felt more pain, despite no physical pain stimulation, compared to the participants in the nonocebo condition. Therefore, the first hypothesis was supported. Yet, the second hypothesis predictJULY 2020

Can conscious guilt feelings incite nocebo pain?

ing that those who wrote guilt-inducing memories would feel more pain than those who wrote neutral memories and third hypotheses predicting that the participants who had nocebo pain would report less guilt than the participants who had no pain was not supported. Stated differently, conscious guilt did not lead to more pain in nocebo manipulation, and nocebo pain did not lead to a decrease in guilt feelings.

Despite moderate to large effect sizes for the nocebo studies, the majority of the previous studies included physical stimulation to create nocebo effect.[18] The only report of nocebo pain induction without any physical stimulation comes from Schweiger and Parducciâ&#x20AC;&#x2DC;s study.[14] In their study, two-thirds of the participants reported mild pain after weak and strong nocebo manipulations. The researchers prepared a realistic environment that included a shock inducer, power supply, oxygen tank, noise generator, amplifier, polygraph, brightness comparator consisting of a luminous disc with a concentric surrounding ring, and a dental chair.[14] All these instruments apparently increased suggestibility[43] and anxiety,[19,20] which are underlying mechanisms for nocebo. There were no decorative materials except for an EEG cap and a computer in the present study, yet the nocebo effect could still be created without any physical stimulation.

One possible explanation about successful nocebo manipulation could be demand characteristics,[44] which means the participants behave in ways to satisfy the expectations of the researchers. Yet in the current study, if the participants reported any level of pain, they were asked to define their pain and its location. This procedure may have prevented reporting of pain due to demand characteristics.

Second and third hypotheses of the study were not supported. The findings of the present study failed to support Engelâ&#x20AC;&#x2122;s argument that conscious guilt feelings may lead to psychogenic pain. His clinical observations were based on what he called pain prone patients who have specific psychodynamics regarding pain experiences.[9] Blumer and Heilbornn[45] identified clinical features of pain-prone patients as having desire for surgery, denial of affective and interpersonal problems, engaging in excessive activities before onset of pain, and having a depression masked by pain. The current study included participants from a generally healthy population and JULY 2020

not pain prone patients as defined by Blumer and Heilbornn, which might explain the reason for lack of support for second and third hypotheses.

Another reason why the second and third hypotheses were not supported may be the absence of unconscious guilt processing in the present study. According to Freud, guilt must be unconscious to finds its expression as an illness or symptom.[28] For example, utilizing a suppression paradigm, Quartana and Burns[46] found that suppressed anger in experimental settings leads to higher pain sensitivity compared to suppressed of anxiety or no suppression.

Moreover, symptom formation of unconscious conflict does not always have to be bodily pain. Maybe, the participants had already punished themselves for their past guilt acts in other ways. Consequently, the participants did not use nocebo pain as a way of expiation in the present study.

Also contrary to the present findings, Bastian, Jetten, and Fasoli[32] found that experiencing physical pain in cold pressor alleviated guilt feelings of the participants induced by writing a memory in which they socially excluded another person. Moreover, guilty participants rated their pain as higher than controls.

Several possible explanations for this contradiction can be proposed. First of all, in the present study, the guilt induction was done by asking participants to write memory that they still feel guilty about. However, the context of the guilty act was not fixed. Their expected redemption may be something other than experiencing physical pain, like an eye for an eye approach in the context of the guilty act. Physical pain may be a punishment for socially excluding someone,[32] but not for other types of guilty acts.

Second, previous studies revealed that emotional manipulations such as reading emotionally charged texts, listening to music, and looking at emotional pictures tend to modulate unpleasantness of pain more than pain sensation.[47] In the current study, however, the participants were not asked to differentiate between the unpleasantness of pain and the sensation of pain. It is possible that the experience of writing about a guilt-inducing memory decreased the unpleasantness of pain but not the sensation of pain, which in turn moderated the response given to pain questions.

135

A RI PAIN Third, De Wall and Baumeister[48] found that social exclusion leads to higher pain threshold and tolerance in the physical pressure application procedure.

This effect is called emotional numbness in which social exclusion leads to emotional and physical insensitivity by impairing the functioning of the emotional system. This is because emotional and physical pain experiences share the same physiological mechanisms.[49] Baumeister, Stillwell and Heatherton[50] asserted that guilt may be a form of anxiety resulting from the threat of social exclusion. Similarly, negative evaluation by others and inability to meet cultural standards and norms may lead to self-conscious emotions like shame and guilt.[51] Therefore, it may be assumed that guilt primes the expectation of social exclusion, and such an expectation may inhibit the effect of guilt feelings on pain ratings.

Fourth, Eisenberger, Lieberman, and Williams[52] examined neural correlates of social exclusion and found anterior cingulate cortex (ACC) activation during social exclusion. It is known that ACC is also activated during experiencing physical pain,[53] and it is related to affective aspects of pain.[54] Interestingly, the patients having cingulotomies (surgical excision of some parts of ACC) for chronic pain complaints continued to feel physical pain, but they were not disturbed by it.[53] Neuroscience studies about guilt feelings suggested that ACC may be a guilt-processing unit in a wider neural network.[55] ACC was also activated as a result of nocebo pain expectations.

[21,23] ACC seems to be an intersection area for social pain, physical pain, guilt, and nocebo.

Therefore, it can be asserted if both conscious experience of guilt feelings and physical pain activate ACC, after a conscious guilt induction, simultaneous experience of physical pain may be inhibited. Stated differently, guilt feelings are experienced as an inner unpleasantness, and they override the unpleasantness of nocebo pain. This effect may make the participants less likely to report nocebo manipulation as a pain sensation because the participants may not feel the unpleasantness of pain. On the other hand, unconscious guilt may not activate ACC, and thus, unpleasantness of guilt would be absent. Under such circumstances, guilt may be experienced as physical pain due to shared neural circuitry. For instance, suppression or repression of guilt may produce an effect on ACC and leads to exacerbated physical pain symptoms.

136

The third hypothesis was that experiencing nocebo pain would be an expiation for the guilt feelings, and participantsâ&#x20AC;&#x2122; guilt feelings would consequently decrease, which was not supported. The results, however, suggested that guilt feelings of the participants in both the nocebo and the no-nocebo conditions decreased from pre-manipulation to post-manipulation, possibly due to the effect of time. The use of Time-Wall Estimation Task may have contributed to this effect. The task was easy to complete, and as a result, it may have increased the selfesteem of the participants. In a study examining the relationship between proneness to guilt and selfesteem, the two were found to be negatively and moderately correlated.[56] Therefore, in the present study, the guilt feelings may have decreased due to increased self-esteem.

Moreover, writing about guilt inducing experience with affective details may serve as an expressive writing task.[57] It was repeatedly found that disclosing an emotional experience by writing or telling about it may reduce distress later in time.[58] Thus, writing about guilt inducing experience with emotional details may have decreased guilt feelings of the participants in time two.

Finally, although there was a significant nocebo manipulation, it may have been too mild to be effective or experienced as punishment, because, mean pain rating of the participants who reported pain was only 1.946 on a 0 to 10 point scale. Bastian, Jetten, and Fasoli,[32] on the other hand, used physical pain manipulation by a cold pressor and found that physical pain can alleviate the effects of guilt. The authors reported that the mean pain ratings for pain condition were 2.79 on a 0â&#x20AC;&#x201C;5 point scale. Therefore, higher degrees of pain that are physically induced may have an effect on guilt feelings, while to lower degrees pain that is not physically induced may not.

Limitations The study had several limitations. First of all, the sample size could have been larger. Moreover, the participants were assigned to four conditions by their registration order in the SONA system, because the researchers did not expect any pre-existing differences in independent variables. Yet, random assignment of the participants to the groups could JULY 2020

Can conscious guilt feelings incite nocebo pain?

have improved internal validity. The study may have lacked an anxiety-provoking experimental environment, as described by Schweiger and Parducci.[14] There are no standard environmental settings or materials to induce nocebo effects; but, further studies can pay attention to characteristics of the environment in which the experiment is conducted and materials used for nocebo manipulation.

Chronic pain problems have been a controversial topic, and their investigation should involve a biopsychosocial approach. Yet, existing research seems to be rather narrow, focusing only on the psychological or the biological mechanisms. A more holistic understanding of the patients’ experiences can benefit both the researchers and the clinicians.

Guilt feelings were induced through consciously activated autobiographical memories. There are several other ways of inducing guilt in more experiential and disguised ways.[59] In addition, despite being consciously activated, the participants can be asked to suppress their feelings before nocebo manipulation.[34] Further studies may apply more subtle ways of inducing guilt, or they may examine the effects of unconscious guilt on nocebo pain responses throughout suppression.

Acknowledgements: EEG Cap used in the study was provided by Balkar Erdoğan from Middle East Technical University Electrical and Electronics Engineering Department. Assoc. Prof Ahmet Uysal and Assoc. Prof.

Tolga Esat Özkurt provided significant contributions and feedbacks for design of the study. Undergraduate psychology students Zeynep Bilsel, Sinem Çelik, and Büşra Karagöz worked voluntarly during data collections procedures.

Conclusion Despite limitations, the results demonstrated once more that mild physical pain could be psychologically induced without any physical stimulation.

Therefore, nocebo phenomena may partially explain non-organic somatic complaints of clients. For example, somatic complains of hypochondriasis could stem from the nocebo effect. The patients’ anticipation about having an organic illness on some part of the body can actually conceive somatic sensations via anticipation anxiety. Moreover, later, these sensations may be interpreted as serious signs of an illness by the patients.

Effects of unconscious guilt feelings on acute and chronic pain experiences still require further investigation. Hypothetically, unconscious or suppressed guilt feelings may exacerbate experiencing physical pain, and they may be a mechanism behind chronic pain complaints. Also, uncovering unconscious guilt feelings in psychotherapy practices may alleviate the client’s physical pain complaints. Considering high comorbidity between depression and chronic pain,[60–64] neural evidence for the prominent role of guilt feelings in depressive disorders,[65] and the inhibiting effect of positive emotions on pain perception,[66] emotional health of clients with chronic pain problems should be a fundamental target of psychotherapeutic interventions.

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Ethics Committee Approval: Ethical approval for this study was provided by the Research Center for Applied Middle East Technical University (date: 08.02.2017, number: 28620816/64).

Conflict-of-interest issues regarding the authorship or article: None declared.

Peer-rewiew: Externally peer-reviewed.

Financial Disclosure: The authors declared that this study has received no financial support.

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doi: 10.14744/agri.2019.97759

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ORIGINAL ARTICLE

A comparison of the ultrasound-guided modified-thoracolumbar interfascial plane block and wound infiltration for postoperative pain management in lumbar spinal surgery patients Lomber spinal cerrahi yapılan hastalarda postoperatif analjezi yönetimi için ultrason eşliğinde yapılan modifiye-torakolomber interfasiyal plan bloğu ve yara yeri infiltrasyonunun karşılaştırılması: Prospektif, randomize çalışma Mürsel EKINCI,1 Bahadır ÇIFTÇI,1 Yunus Oktay ATALAY1

Erkan Cem ÇELIK,2

Ahmet Murat YAYIK,2

Alican TAHTA,3

Summary Objectives: Pain management is an important issue following lumbar spinal surgery. Wound infiltration is a technique that a local anesthetic solution is infiltrated into the tissues around the surgical area. Previous studies reported that US-guided modified thoracolumbar interfacial plane (mTLIP) block after lumbar spinal surgery provided effective analgesia. In this study, we aimed to compare the analgesic efficacy of the US-guided mTLIP block and wound infiltration following lumbar disc surgery.

Methods: 60 patients aged 18–65 years, ASA classification I–II, and scheduled for lumbar disc surgery under general anesthesia were included in the study. US-guided mTLIP block was performed via the lateral approach in group T (n=30), and wound infiltration was performed in group W (n=30). Opioid consumption, postoperative pain scores and adverse effects of opioids, such as allergic reactions, nausea, and vomiting, were recorded.

Results: Opioid consumption and the use of rescue analgesia were significantly lower in group T in all the postoperative periods (1, 2, 4, 8, 16, and 24 h) (p<0.05). The VAS scores for pain during mobility and while at rest were significantly lower in group T than those in group W 8 h after the surgery (p<0.05). The incidences of nausea, vomiting, and itching in group W were higher than the incidences in group T. Conclusion: The mTLIP block provides effective analgesia for the first 24 h following lumbar disc surgery, and it may be an alternative to wound infiltration for pain management.

Keywords: Lumbar spinal surgery, modified thoracolumbar interfascial plane block; postoperative analgesia; wound infiltration.

Özet Amaç: Lomber spinal cerrahi sonrası analjezi yönetimi önemli bir konudur. Yara yeri infiltrasyonu, lokal anesteziğin cerrahi alan etrafındaki dokulara infiltre edildiği bir tekniktir. Daha önceki klinik çalışmalar, lomber spinal cerrahi sonrası ultrason (US) eşliğinde yapılan modifiye torakolomber interfasiyal plan (mTLIP) bloğunun etkili analjezi sağladığını göstermektedir. Çalışmamızda lomber disk cerrahisi sonrası US eşliğinde mTLIP bloğun ve yara infiltrasyonunun analjezik etkinliğini karşılaştırmayı amaçladık.

Gereç ve Yöntem: Çalışmaya, 18-65 yaş arası, ASA I -II sınıfında olan ve genel anestezi altında lomber disk cerrahisi planlanan 60 hasta dahil edildi. Anestezi indüksiyonu yapılıp pron pozisyona alındıktan sonra T grubuna (n=30) lateral yaklaşımla US eşliğinde mTLIP blok, W grubunda ise (n=30) yara yeri infiltrasyonu yapıldı. Opioid tüketimi, postoperatif ağrı skorları ve yan etkiler (allerjik reaksiyon, bulantı, kusma) kaydedildi.

Bulgular: Postoperatif tüm zaman aralıklarında (1, 2, 4, 8, 16 ve 24 saat) opioid tüketimi ve kurtarıcı analjezi kullanımı grup T’de anlamlı olarak düşüktü (p<0.05). İstirahat ve aktivite sırasındaki VAS skorları postoperatif ilk 8 saatte Grup T’de grup W ya göre anlamlı derecede düşüktü (p<0.05). Grup W da bulantı, kusma ve kaşıntı insidansı grup T’den daha yüksekti.

Sonuç: mTLIP blok, lomber disk ameliyatı yapılan hastalarda postoperatif ilk 24 saat boyunca etkili bir analjezi sağlamaktadır ve analjezi yönetimi için yara yeri infiltrasyonuna alternatif olarak uygulanabilir.

Anahtar sözcükler: Lomber spinal cerrahi; modifiye torakolomber interfasiyal plan bloğu; postoperatif analjezi; yara yeri infiltrasyonu.

Department of Anesthesiology and Reanimation, İstanbul Medipol University Faculty of Medicine, Mega Medipol University Hospital, İstanbul, Turkey Department of Anesthesiology and Reanimation, Erzurum Regional Training and Research Hospital, Erzurum, Turkey 3 Department of Neurosurgery, İstanbul Medipol University, Mega Medipol University Hospital, İstanbul, Turkey 1

2

Submitted (Başvuru tarihi) 23.10.2019 Accepted after revision (Düzeltme sonrası kabul tarihi) 19.12.2019 Available online date (Online yayımlanma tarihi) 30.04.2020

Correspondence: Dr. Bahadır Çiftçi. Medipol Mega Üniversite Hastanesi, Anesteziyoloji ve Reanimasyon Kliniği, Bağcılar, İstanbul, Turkey.

Phone: +90 - 532 - 503 44 28 e-mail: bciftci@medipol.edu.tr, baha_cftci@hotmail.com © 2020 Turkish Society of Algology

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An mTLIP block for analgesia management after lumbar spinal surgery

Introduction

Material and Methods

Lumbar discectomy surgey is one of the most common surgeries performed for leg and back pain. Postlumbar surgery pain can be severe and may progress to chronic pain during the postoperative period.[1] Therefore, pain management is important. Effective postoperative pain management enables early mobilization and shorter durations of hospital stays and may also reduce hospitalization-related complications, such as infections and thromboembolism.[1–3]

Ethical approval for this study was provided by the Clinical Research Ethical Committee of Istanbul Medipol University, Istanbul, Turkey. All the patients provided written informed consent.

The most common analgesic agents used postoperatively are opioids.[4] However, parenteral opioids may result in undesirable adverse events, such as nausea, vomiting, itching, sedation, and respiratory depression.[4] Various methods are available to reduce the use of systemic opioids in postoperative pain management, one of which is local anesthetic infiltration (wound infiltration) into the operation site. Several studies reported that wound infiltration can reduce opioid consumption following surgery.[5–7] Regional anesthesia techniques can also be used to manage postoperative pain. Such techniques have a high success rate, especially if they are applied with ultrasound (US) guidance, as US improves visualization, thereby reducing potential complications. Thoracolumbar interfascial plane (TLIP) block was first described by Hand et al. in 2015.[8] In this technique, a local anesthetic solution is injected between the multifidus and logissimus muscles nearly at the level of the third lumbar vertebra (classic technique). However, there is a risk of neuroaxial injury in this technique, and sonographic imaging of this technique may be difficult.[9] Therefore, Ahiskalioglu et al.[9,10] described the US-guided modified-TLIP (mTLIP) block. Using their modified technique, a local anesthetic solution was injected between the longissimus and iliocostalis muscles. They reported that the sonographic visualization was easier and the complication rate was lower than the classic technique.[10] Previous research reported that US-guided mTLIP block after lumbar spinal surgery provided effective analgesia.[11] In this study, we compared the analgesic efficacy of the USguided mTLIP block and wound infiltration following single-level lumbar disc surgery. The primary aim was to compare postoperative opioid consumption.

The secondary aim was to evaluate postoperative pain scores and adverse effects of opioids, such as allergic reactions, nausea, and vomiting.

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60 patients underwent lumbar spinal surgery were included in the study. The patients were aged 18–65 years, American Society of Anesthesiologists classification I–II, and scheduled for single-level lumbar disc surgery under general anesthesia. The exclusion criteria were a history of bleeding diathesis, anticoagulant treatment, known local anesthetics and opioid allergies, skin infections at the site of a needle puncture, pregnancy or lactation, and refusal to accept the procedure. The patients were randomly divided into two groups using a randomizing computer program: a TLIP block group (group T) and a wound infiltration group (group W), with 30 patients in each group).

General anesthesia After placement of a peripheral IV cannula, the patients were monitored with electrocardiography (ECG), noninvasive blood pressure, and pulse oximetry (SpO2). Midazolam (2 mg) was administered intravenously. General anesthesia was induced via IV administration of propofol (2–2.5 mg/kg) and fentanyl (1–1.5 µg/kg). After administration of rocuronium bromide (0.6 mg/kg), orotracheal intubation was performed. The patients were placed in the prone position. Anesthesia maintenance was achieved with sevoflurane in a mixture of oxygen and fresh air, and remifentanil was administered at an infusion rate of 0.01–0.1 µg/kg/min.

The patients’ heart rates, respiratory rates, peripheral oxygen saturation, invasive arterial pressures, and end-tidal carbon dioxide levels were recorded at 5-min intervals throughout the surgery. Controlled mechanical ventilation was initiated with a tidal volume of 8 ml/kg, fresh gas flow rate of 2 L per min, respiratory rate of 12 breaths per min (I:E ratio of 1:2), peak airway pressure of 30 cm H2O, and end tidal carbon dioxide (CO2) value of 30–35 mmHg. All the patients underwent microscopically lumbar discectomy and partial hemilaminectomy surgery using the same technique, and the same surgical team performed all the surgeries.

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(a)

(b)

(c)

Figure 1. (a) Sonographic anatomy of the block region. (b) The needle direction between longissimus and iliocostalis muscles. (c) Spread of local anesthetic. LA indicates local anesthetic.

Block technique After the induction of anesthesia and placement of the patient in a prone position, US-guided mTLIP block was performed via the lateral approach in group T, and wound infiltration was performed in group W. In group T, the block was performed bilaterally under aseptic conditions using the GE Vivid Q® US device (GE Healthcare, USA) with a high-frequency 12-MHz linear US probe. The probe was covered with a sterile sheath and placed vertically at the L3 vertebrae level. After visualizing the hyperechoic shadow of the spinous process and interspinous muscles as an anatomical guide point, the probe was moved forward in a lateral direction to visualize the longissimus and iliocostal muscles (Fig. 1a). As shown in Figure 1b, using the in-plane technique, a 22-G, 50-mm block needle (Braun Stimuplex Ultra 360, Germany) was inserted between the muscles in a medial-to-lateral direction in the interfascial plane.[9,10] Once the needle tip was placed within the interfascial plane and after careful aspiration to rule out intravascular needle placement, 2 ml of saline was injected to confirm the accuracy of the injection site. A dose of 0.25% bupivacaine (20 ml) was then injected in each side (total 40 ml) (Fig. 1c).

In group W, a dose of 0.5% bupivacaine (20 ml) was injected for wound infiltration into the surgery site.

All the patients received IV paracetamol (1 g) 30 min before the end of the surgery, as well 4 mg of ondansetron IV. At the end of the surgery, neuromuscular blockage was antagonized using IV atropine (0.015 mg/kg) and neostigmine (0.03 mg/kg).

The patients were extubated after visualizing sufficient spontaneous respiration and transferred to 142

the postanesthesia care unit. After they attained a modified Aldrete score of 12, the patients were discharged from the unit.

For postoperative analgesia, a dose of 1 g of paracetamol (IV) was administered routinely, every 8 h. All the patients received fentanyl via a patientcontrolled analgesia device. The protocol was a 20 mcg bolus without an infusion dose, 20-min lockout time, and 4-h limit. An anesthesiologist blinded to the procedure performed the postoperative pain assessment using the visual analogue scale (VAS) (0=no pain, 10=the most severe pain felt). The VAS scores at rest and during mobilization were recorded at postoperative 1, 2, 4, 8, 16, and 24 h. In cases where VAS scores were ≥4, 0.5 mg/kg of meperidine was administered intravenously.

The sedation level was assessed using a 4-point sedation scale (0=awake, eyes open, 1=sleepy but responding to verbal stimulus, 2=sleepy and difficult to evoke a response, 3=sleepy, not aroused by shaking). Postoperative opioid consumption, adverse events, such as nausea, vomiting, and itching, and block-related complications were recorded.

Statistical analysis A power analysis was performed to determine the required sample size to assess total postoperative opioid consumption. The effect size was 3.44 (95% confidence interval), therefore indicating that the sample size was sufficient. Statistical analyses were performed using SPSS 20.0 for Windows (IBM, NY, USA). The Kolmogorov–Smirnov test was used to evaluate the data distribution. Pearson’s chi-square test was applied to categorical data in the groups.

The student’s T test was used to check differences between the groups, at a significance level of 5% JULY 2020

An mTLIP block for analgesia management after lumbar spinal surgery

Table 1. Comparison of patients’s characteristics, surgical duration and level of surgery between group T and group W

Group T (n=30)

Age Male/Female ASA I/II Weight (kg) Height (cm) Duration of anesthesia Surgical duration (min) Level of surgery (L5-S1 /L4-L5/L3-L4/L2-L3)

Group W (n=30)

46.90±9.46 13/17 15/15 76.33±10.68 169.63±9.66 116.76±27.26 85.43±24.45 2/22/6/0

p

47.90±10.819 0.705α 16/14 0.438β 17/13 0.605β 81.27±12.03 0.098α 168.10±10.17 0.552α 108.76±21.08 0.209α 74.43±18.82 0.056α 1/14/14/1 0.097β

Values are expressed mean±standart deviation or number. ASA: American Society of Anesthesiologist; kg; kilogram; cm: centimeter; min: minutes; L: Lumbar; S: Sacral; α: p>0.05 Student’s T test between groups; β: p>0.05 Chi-square test between groups.

Enrollment

Assessed for eligibility (n=68) Excluded (n=8) • Not meeting inclusion criteria (n=5) • Declined to participate (n=3) • Other reasons (n=0) Randomized (n=60)

Allocation Allocated to intervention TLIP block group (n=30) • Received allocated intervention (n=30) • Did not allocated intervention (give reasons) (n=0)

Lost to follow-up (give reasons) (n=0) Discontinued intervention (give reasons) (n=0)

Analysed (n=30) • Excluded from analysis (give reasons) (n=0)

Follow-up

Analysis

Allocated to intervention wound infiltration group (n=30) • Received allocated intervention (n=30) • Did not receive allocated intervention (give reasons) (n=0)

Lost to follow-up (give reasons) (n=0) Discontinued intervention (give reasons) (n=0)

Analysed (n=30) • Excluded from analysis (give reasons) (n=0)

Figure 4. CONSORT flow diagram of the study.

for normally distributed continuous variables. Descriptive statistics are expressed as mean±standard deviation.

Results This study comprised 60 patients, with 30 (50%) patients in each group. There were no statistically significant intergroup differences in terms of age, weight, length, American Society of Anesthesiologists status, duration of anesthesia, duration of surgery, and surgical level (p>0.05) (Table 1). The results are presented in a Consolidated Standards JULY 2020

of Reporting Trials flow diagram in Figure 4. Opioid consumption was significantly lower in group T as compared with that in group W in all the postoperative periods (1, 2, 4, 8, 16, and 24 h) (p<0.05). The use of rescue analgesia in group T was significantly lower than that in group W (p<0.05) (Table 2). The VAS scores for pain during mobility and while at rest were significantly lower in group T than those in group W 8 h after the surgery (p<0.05) (Table 3).

The incidences of nausea, vomiting, and itching in group W were higher than those in group T. There were no between-group differences in other adverse effects (Table 4).

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A RI PAIN Table 2. Comparison of opioid consumptions and rescue anlagesia between group T and group W Opioid consumption

Group T (n=30)

Group W (n=30)

p

1st hour 2nd hour 4th hour 8th hour 16th hour 24th hour Rescue analgesia (Y/N)

5.3±11.6 11.3±19.4 18.0±24.2 30.0±27.6 50.6±26.1 58.0±32.0 7/23

42.0±15.1 82.6±2.61 129.3±43.2 168.0±54.2 198.6±62.5 223.3±74.1 15/15

<0.001α <0.001α <0.001α <0.001α <0.001α <0.001α 0.032β

Values are expressed mean±standart deviation. α: p<0.001 Student’s T test between groups; β: p<0.05 Chi Square Test between groups.

Table 3. Comparison of VAS scores between group T and group W VAS (hour)

Group T (n=30)

Group W (n=30)

Passive 0 0.60±0.85 nd Passive 2 0.37±0.61 Passive 4st 0.20±0.48 Passive 8st 0.50±0.57 Passive 16st 1.23±1.20 Passive 24st 0.73±0.69 Active 0 1.30±1.39 nd Active 2 0.93±1.04 Active 4st 0.97±0.96 Active 8st 1.20±0.88 Active 16st 1.97±1.56 Active 24st 1.13±0.90

p

3.77±1.27 <0.001α 2.80±1.27 <0.001α 2.63±0.99 <0.001α 1.70±0.98 <0.001α 1.27±0.94 0.906β 1.00±0.64 0.127β 4.60±1.22 <0.001α 3.57±0.97 <0.001α 3.47±1.04 <0.001α 2.37±1.03 <0.001α 1.77±1.10 0.569β 1.53±0.90 0.090β

Values are expressed mean±standart deviation. VAS: Visual analog pain scale; α: p<0.001 Student’s T test between groups; β: p>0.05 Student’s T test between groups.

Discussion This study compared the analgesic efficacy of an US-guided mTLIP block with wound infiltration for postoperative analgesia management after lumbar discectomy/hemilaminectomy. The results demonstrated that mTLIP block provided better analgesia, with decreased VAS scores and opioid consumption, in addition to a reduced incidence of adverse effects, as compared with wound infiltration. There were no complications related to the block or local anesthetics.

Wound infiltration is a technique in which a local anesthetic solution is infiltrated into the tissues around the surgical area. Many studies have reported the poor effectiveness of wound infiltration in terms of opioid consumption.[2,6,12–14] Its underlying mechanism depends on absorption of the local anesthetic solution by the injected tissues. Although wound in144

Table 4. Comparison of side effects between group T and group W

Group T Group W (n=30) (n=30)

Breathing depression Sedation/Confusion Somnolence Urinary retention Consitpation Nausea Vomiting Pruritis

0 0 0 0 0 2 0 1

p

0 1.000α 0 1.000α 0 1.000α 0 1.000α 0 1.000α 8 0.038β 5 0.020β 6 0.044β

Values are expressed as a number. α: p>0.05 Chi-square test between groups; β: p<0.05 Chi-square test between groups.

filtration is easy and simple to perform, it has a number of disadvantages. First, the local anesthetic is inJULY 2020

An mTLIP block for analgesia management after lumbar spinal surgery

jected blindly into the tissues. Second, the method provides analgesia only at the site of administration.

The ventral motor root and dorsal sensory root fuse to form the spinal nerve. The spinal nerve then divides into two rami after exiting the intervertebral foramen: the large ventral ramus and smaller dorsal ramus. The dorsal ramus runs around the facet joints, innervates ligaments, joints, and paravertebral muscles; and provides cutaneous sense from the vertex to the coccyx.[15] These nerves can be blocked by USguided regional anesthetic techniques (interfascial plane blocks). Such techniques have a number of advantages. For example, they are easy to perform and provide improved visualization and reduced complication rates.[9,10,16â&#x20AC;&#x201C;18] TLIP block is a type of interfascial plane block that targets the dorsal rami of the thoracolumbar nerves.[8] In this technique, a local anesthetic solution is injected between the multifidus and logissimus muscles by advancing the needle from the lateral to the medial side (classic technique). A retrospective study reported that TLIP block was effective in analgesia after lumbar laminoplasty surgery.[16] However, there is a risk of inadvertently inducing neuroaxial anesthesia when advancing the needle from the lateral side to the medial side during TLIP block, and sonographic imaging of the longissimus and iliocostalis muscles can be easier than imaging the multifidus and longissimus muscles. Therefore Ahiskalioglu et al.[9,10] described a US-guided mTLIP block via a lateral approach. Using their modified technique, a local anesthetic solution was injected between the longissimus and iliocostalis muscles, and the needle was advanced medial to lateral. As with the classic approach, a number of studies demonstrated the analgesic effectiveness of the mTLIP block after lumber spinal surgery.[11,17] Thus, we used the mTLIP block in this study. In common with the literature, we found that the mTLIP block was an effective postoperative pain management technique after lumbar surgery. In a cadaveric study in which the mTLIP technique was used, the injected solution spread over the transverse process and colored the dorsal rami between the first and fourth lumbar nerves.[18] This finding supports that the mTLIP block provides more effective analgesia than wound infiltration.

In the literature, in a randomized trial evaluating the efficacy of US-guided mTLIP block for postoperative analgesia after spinal surgery, Ahiskalioglu et al.[19] perJULY 2020

formed a bilateral mTLIP block and reported that the mTLIP block decreased opioid consumption and VAS scores compared to the fentanyl PCA control group.

Ueshima et al. also performed a mTLIP block in two patients following lumbar spinal surgery and reported that it had a successful analgesic effect postoperatively.[17] In another case report, Li et al. performed a bilateral mTLIP block in two patients who underwent multilevel spinal fusion surgery.[11] They reported effective pain relief from activity-related pain for 24 h and effective pain relief from rest-related pain for 48 h. Other research demonstrated that the mTLIP block was an effective analgesia technique not only in acute postoperative pain but also in chronic low back pain.

[20] These findings support those of the present study.

In a study, Ince et al.[21] compared the efficacy of USguided TLIP block and wound infiltration for postoperative analgesia following single-level discectomy surgery. They reported that wound infiltration is a simple method compared with TLIP block and it is an effective technique for acute pain management after lumbar discectomy. There are some differencies between this correspondence and our randomized study. Firstly, we performed mTLIP block via lateral approach. mTLIP block has been defined due to it is a simplier method than classical approach. Thus, it may be performed easier. Secondly, the number of patients is 40 in that correspondence. However, we studied this randomized trial in 60 patient. On the other hand, only discectomy was performed as surgical technique in the correspondence. In our study both discectomy and hemilaminectomy were performed surgically. Lastly, our results has showed that mTLIP block provides more effective analgesia than wound infiltration following single-level lumbar spinal surgery. In terms of this, larger sample studies with larger patient populations may be needed to explain these different results.

This study has some limitations. First, we evaluated the analgesic efficacy of the mTLIP block technique for only 24 h following surgery. Thus, the analgesic efficacy of the mTLIP block technique for longer periods, as well as for chronic pain, is unclear. Second, the present study did no include an assessment of the ideal volume and concentration of local anesthetics during TLIP block. Lastly, it would be useful a contrast medium was added to the mixture followed by an anteroposterior X-ray to understand the the exact spread of the injected solution.

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A RI PAIN Further studies with different volumes and concentrations are needed. Studies evaluating the analgesic efficacy of the mTLIP block in different types of lumbar spinal surgical procedures are required.

Conclusion To summarize, we conclude that the mTLIP block provides effective analgesia for the first 24 h following lumbar disc surgery and that it may be an alternative to wound infiltration for pain management after lumbar discectomy and hemilaminectomy surgery.

Ethics Committee Approval: Ethical approval for this study was provided by the Clinical Research Ethical Committee of Istanbul Medipol University (date: 28.12.2018, number: 24).

Conflict-of-interest issues regarding the authorship or article: None declared.

Peer-rewiew: Externally peer-reviewed.

Financial Disclosure: The authors declared that this study has received no financial support.

References 1. McGirt MJ, Ambrossi GL, Datoo G, Sciubba DM, Witham TF, Wolinsky JP, et al. Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal.

Neurosurgery 2009;64(2):338–45.

2. Gurbet A, Bekar A, Bilgin H, Ozdemir N, Kuytu T. Preemptive wound infiltration in lumbar laminectomy for postoperative pain: comparison of bupivacaine and levobupivacaine. Turk Neurosurg 2014;24(1):48–53.

3. Efthymiou CA, O’Regan DJ. Postdischarge complications: what exactly happens when the patient goes home? Interact Cardiovasc Thorac Surg 2011;12(2):130–4.

4. Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, Glaser SE, Vallejo R. Opioid complications and side effects. Pain Physician 2008;11(2 Suppl):S105–20.

5. Teddy PJ, Fabinyi GC, Kerr JH, Briggs M. Bupivacaine infiltration after lumbar laminectomy. Local infiltration in the control of early postoperative lumbar laminectomy pain.

Anaesthesia 1981;36(4):380–3.

6. Ersayli DT, Gurbet A, Bekar A, Uckunkaya N, Bilgin H. Effects of perioperatively administered bupivacaine and bupivacaine-methylprednisolone on pain after lumbar discectomy. Spine (Phila Pa 1976) 2006;31(19):2221–6.

7. Ozyilmaz K, Ayoglu H, Okyay RD, Yurtlu S, Koksal B, Hanci V, et al. Postoperative analgesic effects of wound infiltration with tramadol and levobupivacaine in lumbar disk surgeries. J Neurosurg Anesthesiol 2012;24(4):331–5.

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8. Hand WR, Taylor JM, Harvey NR, Epperson TI, Gunselman RJ, Bolin ED, Whiteley J. Thoracolumbar interfascial plane (TLIP) block: a pilot study in volunteers. Can J Anaesth 2015;62(11):1196–200.

9. Ahiskalioglu A, Yayik AM, Alici HA. Ultrasound-guided lateral thoracolumbar interfascial plane (TLIP) block: Description of new modified technique. J Clin Anesth 2017;40:62.

10. Ahiskalioglu A, Alici HA, Selvitopi K, Yayik AM. Ultrasonography-guided modified thoracolumbar interfascial plane block: a new approach. Can J Anaesth 2017;64(7):775–6.

11. Li C, Jia J, Qin Z, Tang Z. The use of ultrasound-guided modified thoracolumbar interfascial plane (TLIP) block for multilevel lumbar spinal surgery. J Clin Anesth 2018;46:49–51.

12. Gurbet A, Bekar A, Bilgin H, Korfali G, Yilmazlar S, Tercan M. Pre-emptive infiltration of levobupivacaine is superior to at-closure administration in lumbar laminectomy patients.

Eur Spine J 2008;17(9):1237–41.

13. Kjærgaard M, Møiniche S, Olsen KS. Wound infiltration with local anesthetics for post-operative pain relief in lumbar spine surgery: a systematic review. Acta Anaesthesiol Scand 2012;56(3):282–90.

14. Perera AP, Chari A, Kostusiak M, Khan AA, Luoma AM, Casey ATH. Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2017;42(14):1088–95.

15. Maigne R. Innervation of vertebral structures. In: Nieves WL, editor. Diagnosis and Treatment of Pain of Vertebral Origin. 2nd ed. CRC Press, Taylor and France Group; 2006. p. 30-41.

16. Ueshima H, Ozawa T, Toyone T, Otake H. Efficacy of the Thoracolumbar Interfascial Plane Block for Lumbar Laminoplasty: A Retrospective Study. Asian Spine J 2017;11(5):722–5.

17. Ueshima H, Otake H. Clinical efficacy of modified thoracolumbar interfascial plane block. J Clin Anesth 2016;30:74– 5.

18. Ueshima H, Otake H. Ultrasound-guided “lateral” thoracolumbar interfascial plane (TLIP) block: A cadaveric study of the spread of injectate. J Clin Anesth 2017;40:54.

19. Ahiskalioglu A, Yayik AM, Doymus O, Selvitopi K, Ahiskalioglu EO, Calikoglu C, et al. Efficacy of ultrasound-guided modified thoracolumbar interfascial plane block for postoperative analgesia after spinal surgery: a randomizedcontrolled trial. Can J Anaesth 2018;65(5):603–4.

20. Ahiskalioglu A, Yayik AM, Celik EC, Aydin ME, Uzun G. Ultrasound guided modified Thoracolumbar Interfascial Plane block for low back pain management. J Clin Anesth 2019;54:138–9.

21. Ince I, Atalay C, Ozmen O, Ozturk V, Hassan M, Aksoy M, et al. Comparison of ultrasound-guided thoracolumbar interfascial plane block versus wound infiltration for postoperative analgesia after single-level discectomy. J Clin Anesth 2019;56:113–4.

JULY 2020

Agri 2020;32(3):147–151

doi: 10.14744/agri.2019.79847

A RI PAIN

ORIGINAL ARTICLE

Telephone versus self administration of outcome measures in low back pain patients Bel ağrılı hastalarda değerlendirme ölçütlerinin telefon veya kendi kendine uygulanmasının karşılaştırılması Savaş ŞENCAN,1 Alp Eren ÇELENLIOĞLU,2 Naime Evrim KARADAĞ SAYGI5

Serdar KOKAR,3

Fırat ULUTATAR,4

Summary Objectives: Comparison of self-rating method and telephone interview method on outcome measures’ results.

Methods: This cross-sectional study included 100 patients aged 18–40 years who applied to Physical Medicine and Rehabilitation outpatient clinics with mechanical low back pain. Outcome measures [Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDI), Numeric Pain Rating Scale (NPRS), Istanbul Low Back Pain Disability Index (ILBPD] were administered, and the duration of administration was recorded by two different methods. The self-assessment method and scales were administered by patients in the outpatient clinic and the telephone interview method; scales were administered by the researcher via telephone-calls 24 hours after the out-patient visit.

Results: There were no significant differences observed in the results of outcome measures by the method of administration except the Istanbul Low-Back-Pain Disability Index (p=0.030). Outcome measures’ results were highly correlated with one another when administered by different methods and orders of administration. Duration of administration was significantly shorter when outcome measures were administered by telephone interview (p<0.001).

Conclusion: Different methods of administration usually do not have an impact on outcome measure results. However, in some scales like ILBPDI, it may emerge as a factor affecting outcome measures’ results. Therefore, adherence to an initially preferred administration method throughout the follow-up period is important regarding the reliability of the results.

Keywords: Low back pain; scale administration methods; telephone versus self administration.

Özet Amaç: Kendi kendine uygulama ile telefonla uygulama yöntemlerinin değerlendirme ölçütlerinin sonuçlarına etkisi.

Gereç ve Yöntem: : Kesitsel olarak düzenlenen çalışmaya Fiziksel Tıp ve Rehabilitasyon polikliniklerine bel ağrısı şikayeti ile başvurmuş yaşları 18-40 arasında değişen 100 hasta dahil edilmiştir. Değerlendirme ölçütleri [Oswestry Dizabilite İndeksi (ODİ), Roland Morris Dizabilite Skalası (RMDS), Numerik Ağrı Skalası (NAS), İstanbul Bel Ağrısı Skalası (İBAS)] hastalara iki farklı yöntem ile uygulandı ve uygulama süreleri kayıt altına alındı. Kendi kendine uygulama methodunda hastalar değerlendirme ölçütlerini hastanede kendileri doldururken aynı hasta grubuna aynı değerlendirme ölçütleri 24 saat sonar telefon ile değerlendirme metot ile uygulandı.

Bulgular: IBAS dışındaki değerlendirme ölçütlerinin sonuçlarında iki yöntem arasında anlamlı fark saptanmadı. Değerlendirme ölçütü skorları her iki yöntem ve farklı uygulama sırasında birbirleri ile güçlü korelasyon gösterdi. Telefon ile uygulama süresi kendi kendine uygulamaya göre anlamlı ölçüde kısa gözlendi (p<0,001).

Sonuç: Farklı uygulama yöntemlerinin değerlendirme ölçütü skorlarına genellikle etkisi bulunmamaktadır. Ancak IBAS gibi bazı değerlendirme ölçütlerinde yöntem seçimi sonuçları etkileyebilmektedir. Bu sebeple takip sürecinde seçilecek uygylama yönteminin başlangıçta seçilen değerlendirme yöntemi ile aynı olması sonuçların güvenilirliği açısından önem taşımaktadır.

Anahtar sözcükler: Bel ağrısı; değerlendirme ölçütü uygulama yöntemleri; telefon veya kendi kendine.

Division Pain Medicine, Faculty, Department of Physical Medicine and Rehabilitation, Marmara University Faculty of Medicine, İstanbul, Turkey Division Pain Medicine, Department of Physical Medicine and Rehabilitation, Kayseri Erciyes University Faculty of Medicine, Kayseri, Turkey 3 Division Pain Medicine, Department of Physical Medicine and Rehabilitation, İstanbul Cerrahpaşa University Faculty of Medicine, İstanbul, Turkey 4 Division Pain Medicine, Department of Physical Medicine and Rehabilitation, Çukurova University Faculty fo Medicine, Adana, Turkey 5 Department of Physical Medicine and Rehabilitation, Marmara University Medical Faculty, İstanbul, Turkey 1 2

Submitted (Başvuru tarihi) 02.09.2019 Accepted after revision (Düzeltme sonrası kabul tarihi) 12.12.2019 Available online date (Online yayımlanma tarihi) 30.04.2020

Correspondence: Dr. Firat Ulutatar. Çukurova Üniversitesi Tıp Fakültesi, Fiziksel Tıp ve Rehabilitasyon Anabilim Dalı, Balcalı Hastanesi, Ağrı Poliklinikleri, Sarıçam, Adana, Turkey.

Phone: +90 - 322 - 338 60 60 e-mail: firatulutatar@gmail.com © 2020 Turkish Society of Algology

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Introduction Low back pain (LBP) is the most common disorder following common cold. It has a life-time prevalence of 60–90% and an annual incidence of 5–6%.[1,2] It is a significant health problem that affects all age groups and causes workforce loss due to severe disability.

[3–7] Low back pain is the leading cause of disability in persons younger than 45 years and the third most common cause of disability above the age of 45 years.[8] It has been shown that the use of outcome measures has been increasing.[9] These outcome measures can assess many clinical parameters in disabling disorders including quality of life, functional status, pain level, disease progression and treatment monitoring. Oswestry Disability Index (ODI), Istanbul Low Back Disability Index (ILBPDI), Roland Morris Disability Questionnaire (RMDQ), and Numeric Pain Rating Scale (NPRS) are important outcome measures that have reliability and validity in Turkish and are widely used for back pain in clinical practice; the former three being used for disability assessment and the latter for pain assessment.[10–12] Three different methods are used for the administration of these scales, the self-assessment method which was the original administration method, face-to-face interview method, and the telephone interview method.

There is an insufficient data about the impact of the methodological differences on results and durations of administration of these outcome measures.

The aim of our study was to examine the impact of the administration methods on the results and the administration durations of low back pain and disability scales (NPRS, ODI, ILBPDI, RMDQ).

Material and Methods Study group Cross-sectional design study randomly enrolled a total of 100 patients (50 males, 50 females) aged 18–40 years who applied to Marmara University, Physical Medicine and Rehabilitation outpatient clinics. Participants were diagnosed with mechanical low back pain after physical examination and imaging methods between December 2014 and June 2015. Individuals who were illiterate, had low back pain due to inflammatory, neoplastic, or infectious causes, and suffered from psychiatric disorders were excluded. After informing the patients about the outcome measures to be administered 148

and obtaining their consent, they were randomized into two groups to rule out the impact of tiredness on scale results; in which four separate outcome measures were administered in two different orders of administration. Outcome measures were administered in the order of NPRS, ODI, ILBPDI, and RMDQ in the first group (Group A) and in the order of RMDQ, ILBPDI, ODI, and NPRS in the second (Group B). The duration of administration (min) was recorded by using two different methods. The self-assessment method was performed at the time of their outpatient clinic visit and the telephone interview method was performed 24 hours after outpatient visit. All telephone interviews were performed by the same researcher. The outcome measures were administered within the context of the diagnostic process and their results were assessed prior to implementing the planned treatments. The study was approved by Marmara University, Faculty of Medicine, Ethics Committee for Clinical Research (Approval number: 09.2014.0127).

Outcome measures Numeric pain rating scale is used for pain assessment. In this scale, patients are asked to score their pain with a number between 0 and 10, depending on pain intensity. A score of 0 indicates no pain while a score of 10 indicates pain of maximum intensity.

Oswestry Disability Index is used to assess functional status, and it includes 10 questions related to pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, travelling, and the amount of the change of pain. The percentage conversion of the sum of the scores ranging between 1 and 6 obtained by answering these questions were used for the assessment of disability: a percentage of 0% to 20% indicates minimal disability, 20% to 40% moderate disability, 40% to 60% severe disability, 60% to 80% crippled, and 80% to 100% bed bound or exaggerating symptoms.

Roland Morris Disability Questionnaire contains 24 questions related to low back pain intensity and its impact on an individual’s daily activities such as walking, dressing, going upstairs and downstairs, and sleeping. A total score of 0–24 points is obtained by summing responses in the form of yes (0 point) and no (1 point). A total score of 0 refers to no disability and 24 indicates maximum disability.

JULY 2020

Telephone versus self administration of outcome measures in low back pain patients

Table 1. Demographic properties of both groups

Group A

Group B

Total

Age, years, 41.74 (12.88) 41.36 (12.84) 41.55 (12.79) mean (SD) Sex (n)

Female 25 25 50

Male 25 25 50 Education (n)

Primary 21 22 43 Secondary 8 5 13

High school 12 10 22 University 9 13 22 n: Number; SD: Standard deviation.

Istanbul Low Back Pain Disability Index includes 18 questions assessing the effects of low back pain on a person’s activities such as going upstairs and downstairs, walking, bathing, tooth brushing, dressing etc.

A total of 0–90 points are obtained from the answers “without any difficulty” (0 point), “with little difficulty” (1 point), “with some difficulty” (2 points), “with great difficulty” (3 points), “almost impossible” (4 points), and “impossible” (5 points). A total score of 0 indicates no disability and 90 refers to maximum disability.

The Turkish validated versions of outcome measurements were used in our study.

Statistical analysis Data analysis was done using SPSS 16.0 (Statistical Package for the Social Sciences, Inc., Chicago, IL, USA) for Windows software package. Statistical comparisons were done using Chi-Square, independent samples t-test, and Mann Whitney U test. Correlation analysis was performed using Spearman’s correlation analysis. A p value of less than 0.05 was considered statistically significant.

Results Our study included a total of 100 patients, with 50 males and 50 females distributed evenly among two groups. The mean age of the study population was 41.6±12.8 years [Group A 41.7±12.9 years, Group B 41.4±12.8 years]. Forty-three (A=21, B=22) patients were primary school, 13 (A=8, B=5) were secondary school, 22 (A=12, B=10) were high school, and 22 (A=9, B=13) were college graduated. No significant differences were found between the demographic properties of both groups (Table 1).

The analysis of outcome measures results revealed that there were no significant differences between the results of outcome measures by the different administration methods, except ILBPDI. The results of Istanbul Low Back Disability Index were significantly higher in the telephone interview method (p=0.03).

The correlation analysis between the outcome measures showed that the results obtained with both different methods and orders of administration were highly correlated (Table 2). Although the duration of administration of different outcome measures were not significantly different between the groups, the duration of the telephone interview method (9.63 min) was significantly lower than that of the self-rating method (17.6±7.3 min) (p<0.001). The time spent by a physician on the phone for rating low back pain with the outcome measures was independent of age, sex, and educational status while the time spent by a patient for self-rating was directly proportional to educational status.

Discussion In our study, administration methods had no impact on the outcome measures’ results except ILBPDI. Despite the presence of literature reports on the transla-

Table 2. Comparison of the outcome measure results between two administration methods

NRS at Rest NRS Activity OswestryDisability Index Roland Morris ILBPDI

Telephone interview

Self-administration

ICC (%95 CI)

p

4.81 (0–10) 5.97 (0–10) 43.1 (8–98) 13.43 (1–24) 23.18 (1–68)

4.78 (0–10) 6.1 (0–10) 43.22 (8–90) 13.69 (1–24) 21.65 (0–70)

0.914 0.902 0.873 0.918 0.894

0.757 0.227 0.900 0.271 0.030

Data as mean and interquartile range (IQR) (25–75th percentile). ICC: Intracalss correlation coefficient; CI: Confidence interval; ILBPDI: İstanbul Low Back Pain Disability Index; NRS: Numeric Rating Scale. p<0.05 significant.

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149

A RI PAIN tion and validation of ILBPDI, we did not come across with any report on the effects of different methods of administration on the results of ILBPDI.[12] Differences in the results of ILBPDI, but not other outcome measures, suggests an outcome measure-specific factor leading to differences in the comprehensibility of the test by the patient with different methods of administration.

Weinberger et al.[13] found that the telephone interview method lasts shorter than the face-to-face interview method and there were weak-to-moderate correlations between both methods with respect to the results of the emotional, physical function, social function, and pain when used for SF-36 questionnaire in elderly patients. Ariza et al.[14] explored the effects of the administration of the outcome measures BASDI, BASFI, HAQ, ASQoL, and EuroQol by telephone interview 48 hours before hospital admission and by the self-rating method performed by patients at hospital admission in ankylosing spondylitis and psoriatic arthritis. They found that the results of the two administration methods were in good correlation with each other, but the telephone interview method had a shorter duration.

The findings of our study were in accordance with those reported by Ariza et al. in that the results of both methods were highly correlated and similar to the results of both studies, the duration of the telephone interview method was shorter.[13,14] At the same time, that the duration being independent of educational status provides a significant advantage for the telephone interview method.

Limitations Our study has some limitations such as; a relatively small study population, absence of the assessment by face-to-face interview method and absence of a separate patient group in which the two administration methods were administered in a different order. Also cost analysis with the telephone interview method and the possible impact of instantaneous moods of patients on the outcome measure results were not considered. Nevertheless, it is a valuable study in that it has showed usually the results of outcome measures by using different administration methods had good correlations with each other. On the other hand, it is not valid for all outcome measures. Consequently, the administration method can 150

become a factor that may directly affect outcome measures results and this information provides an important contribution to the limited literature knowledge about this subject.

Conclusion Different methods of outcome measures administration usually don’t have an impact on the results. But it may be a factor that influence the results depending on the outcome measure administered. Thus, it is important for the reliability of results to adhere to the initially used method of administration of some outcome measures during follow-up of their clinical use. The significant time-saving advantage independent of educational status provided by the telephone interview method by virtue of a significantly shorter administration time should also be taken into consideration for all outcome measures.

Ethics Committee Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards (Approval number: 09.2014.0127).

Informed Consent: Informed consent was obtained from all individual participants included in the study.

Conflict-of-interest issues regarding the authorship or article: None declared.

Peer-rewiew: Externally peer-reviewed.

Financial Disclosure: The authors declared that this study has received no financial support.

References 1. Frymoyer JW, Pope MH, Costanza MC, Rosen JC, Goggin JE, Wilder DG. Epidemiologic studies of low-back pain. Spine (Phila Pa 1976) 1980;5(5):419–23.

2. Kelsey JL, White AA 3rd. Epidemiology and impact of lowback pain. Spine (Phila Pa 1976) 1980;5(2):133–42.

3. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000;84(1):95–103.

4. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 2008;8(1):8–20.

5. Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA 2003;290(18):2443–54.

6. van Tulder MW, Koes BW, Bouter LM. A cost-of-illness study of back pain in The Netherlands. Pain. 1995;62(2):233–40.

7. Gelalis ID, Arnaoutoglou E, Pakos EE, Politis AN, Rapti M, Xenakis TA, et al. Effect of interlaminar epidural steroid in-

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Telephone versus self administration of outcome measures in low back pain patients jection in acute and subacute pain due to lumbar disk herniation: a randomized comparison of 2 different protocols.

Open Orthop J 2009;3:121–4.

8. Weinstein SM HS. Rehabilitation of the patient with low back pain. In: Delisa JA, Gans BM, editors. Rehabilitation Medicine: Principles and Practice. Philadelphia: Lippincott; 1993. p. 996–1017.

9. Guillemin F. Functional disability and quality-of-life assessment in clinical practice. Rheumatology (Oxford) 2000;39 Suppl 1:17–23.

10. Yakut E, Düger T, Oksüz C, Yörükan S, Ureten K, Turan D, et al. Validation of the Turkish version of the Oswestry Disability Index for patients with low back pain. Spine (Phila Pa 1976) 2004;29(5):581–5.

11. Küçükdeveci AA, Tennant A, Elhan AH, Niyazoglu H. Validation of the Turkish version of the Roland-Morris Disabil-

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ity Questionnaire for use in low back pain. Spine (Phila Pa 1976) 2001;26(24):2738–43.

12. Duruöz MT, Özcan E, Ketenci A, Karan A. Development and validation of a functional disability index for chronic low back pain. J Back Musculoskelet Rehabil 2013;26(1):45– 54.

13. Weinberger M, Nagle B, Hanlon JT, Samsa GP, Schmader K, Landsman PB, et al. Assessing health-related quality of life in elderly outpatients: telephone versus face-to-face administration. J Am Geriatr Soc 1994;42(12):1295–9.

14. Ariza-Ariza R, Hernández-Cruz B, Navarro-Compán V, Leyva Pardo C, Juanola X, Navarro-Sarabia F. A comparison of telephone and paper self-completed questionnaires of main patient-related outcome measures in patients with ankylosing spondylitis and psoriatic arthritis. Rheumatol Int 2013;33(11):2731–6.

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doi: 10.14744/agri.2019.65390

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ORIGINAL ARTICLE

Ultrasound detection of sciatic nerve movements with ankle dorsiflexion/plantar flexion: Prospective comparative study of a novel method to locate the sciatic nerve Siyatik sinir hareketinin ayak bileği dorsifleksiyon ve plantar fleksiyonuyla ultrason eşliğinde görüntülenmesi: Siyatik sinirin yerinin belirlenmesinde yeni bir yöntem Onur BALABAN,1

Merve YAMAN,1

Tayfun AYDIN,1

Ahmet MUSMUL2

Summary Objectives: It is possible to observe the in-vivo movements of nerves using real-time ultrasound. In this study, we aimed to visualize the movements of the sciatic nerve as a guide to identify the sciatic nerve to distinguish from surrounding tissue.

Methods: This trial was a prospective, cross-over comparative study. We included 25 healthy volunteers in this study. The movements of the sciatic nerve were visualized in the transverse view at popliteal and midthigh levels using ultrasonography. Anterior-posterior movements were assessed by measuring skin-to-nerve distance. The distances were measured during maximum ankle dorsiflexion, maximum plantar flexion and neutral position and compared with each other. We also evaluated the quality of dynamic (real-time) rotation/lateral movements of the sciatic nerve by assigning a subjective observer score.

Results: The movement of sciatic nerve was significant at popliteal region with active and passive ankle dorsiflexion which was 0.32 cm and 0.23 cm respectively (p=0.003). The movement of sciatic nerve was significant at midthigh region with active and passive ankle plantar flexion which was 0.11 cm and 0.01 cm respectively (p<0.001). Excellent rotation/lateral movement was observed in subjects at popliteal region and good rotation/lateral movement was observed at midthigh level.

Conclusion: Sciatic nerve movement can be observed with ankle dorsiflexion and plantar flexion in the transverse plane at popliteal and midthigh locations under real time ultrasound. This preliminary study suggest that observing the movements of sciatic nerve is potentially valuable in clinical sciatic nerve blocks for facilitating the localization of the sciatic nerve.

Keywords: Ankle dorsiflexion; midthigh; plantar flexion; popliteal; sciatic nerve movement; ultrasound.

Özet Amaç: Sinirlerin in vivo hareketlerini gerçek zamanlı ultrason kullanarak gözlemlemek mümkündür. Siyatik siniri etrafındaki dokudan ayırt etmek ve tanımlamak için bir kılavuz olarak hareketlerini göstermeyi amaçladık.

Gereç ve Yöntem: Bu araştırma prospektif çapraz karşılaştırmalı çalışma olarak planlandı. Bu çalışmaya, 25 gönüllü dahil ettik.

Siyatik sinirin hareketleri ultrasonografi kullanılarak popliteal ve orta uyluk seviyelerinde enine kesitlerde görüntülendi. Ciltsinir mesafesi ölçülerek sinirin ön-arka hareketi değerlendirildi. Mesafeler, maksimum ayak bileği dorsifleksiyonu, maksimum plantar fleksiyon ve nötr pozisyonda ölçüldü ve birbirleriyle karşılaştırıldı. Ayrıca, siyatik sinirin dinamik (gerçek zamanlı) rotasyon/lateral hareketleri subjektif bir gözlemci puanı verilerek değerlendirildi.

Bulgular: Siyatik sinirin hareketi popliteal bölgede aktif ve pasif ayak bileği dorsifleksiyonunda, sırasıyla 0,32 cm ve 0,23 cm olarak ölçüldü ve anlamlı bulundu (p=0,003). Siyatik sinirin hareketi orta uylukta, aktif ve pasif ayak bileği plantar fleksiyonu ile sırasıyla 0,11 cm ve 0,01 cm olarak ölçüldü (p<0,001). Popliteal bölgede iyi derecede rotasyon/lateral hareket, orta uylukta orta seviyede rotasyon/lateral hareket gözlendi.

Sonuç: Gerçek zamanlı ultrason görüntüleme ile popliteal ve orta uyluk seviyelerinde enine kesitlerde ayak bileği dorsifleksiyonu ve plantar fleksiyonu ile siyatik sinir hareketi gözlenmiştir. Siyatik sinirin hareketlerini gözlemlemek, siyatik sinirin lokalizasyonunu kolaylaştırmak için siyatik sinir bloklarında potansiyel olarak faydalı olabilir.

Anahtar sözcükler: Ayak bileği dorsifleksiyon; orta uyluk; plantar fleksiyon; popliteal; siyatik sinir hareketi; ultrason.

Department of Anesthesiology and Pain Medicine, Kütahya Health Sciences University Hospital, Kütahya, Turkey Department of Medical Services and Techniques, Eskişehir Osmangazi University, Vocational School of Health Services, Eskişehir, Turkey

1 2

Submitted (Başvuru tarihi) 18.10.2019 Accepted after revision (Düzeltme sonrası kabul tarihi) 12.12.2019 Available online date (Online yayımlanma tarihi) 05.05.2020

Correspondence: Dr. Merve Yaman. Kütahya Sağlık Bilimleri Üniversitesi Hastanesi, Anesteziyoloji ve Ağrı Hastalıkları Anabilim Dalı, Kütahya, Turkey.

Phone: +90 - 274 - 231 66 60 e-mail: drmerveyaman@hotmail.com © 2020 Turkish Society of Algology

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Ultrasound detection of sciatic nerve movements to identify location

Introduction In the past decade, ultrasound guided techniques have become the popular method for blocking the sciatic nerve. Although ultrasound guidance is helpful for localization of the sciatic nerve (SN), depth of the nerve at thigh may complicate the anatomical distinction of the nerve from the surrounding tissues.[1,2] Sciatic nerve echogenicity is similar to the surrounding fatty tissues, muscles and the echogenicity may vary at different tissue levels along the thigh. Even though ultrasound technology is improving fast, the ability to visualize a detailed image of the sciatic nerve with surrounding/inner tissue layers and visualization of local anesthetic spread may be limited with a 2-dimentional conventional ultrasound machine.[3] It was noted that 37.5% of patients have a poor or average image quality and required nerve stimulation to confirm ultrasonographic appearance of the sciatic nerve.[2] Nerve stimulators are still needed not only to verify the location of the sciatic nerve but also to avoid intraneural injection and improve patient safety. However, use of a nerve stimulator to assist ultrasound guidance and to confirm location of SN may be time consuming and uncomfortable and even in some cases, it can fail to elicit a motor response to identify the SN.[4,5] Therefore, a method to allow ultrasound visualization of sciatic nerve movements would be of value regarding sciatic nerve blocks, particularly for the conditions where it is difficult to distinguish the nerve from surrounding tissues.

Neural mobilization is a well-documented modality within the literature.[6] A peripheral nerve is able to slide and stretch to accommodate changes in its bed length during joint movements.[7] It is possible to observe the in vivo sciatic nerve movements of neural glide, slide or stretching movement by using realtime ultrasound imaging.[8] Recent ultrasound studies have demonstrated that it is possible to visualize and quantify sciatic nerve movement, with reasonable reliability.[9] Observing the real-time movement of the sciatic nerve at popliteal or thigh levels may help to facilitate to identify the SN and distinguish it from the surrounding fascial layers and soft tissues. Based on previous neural mobilization studies, we hypothesized that a clear movement of the sciatic nerve can be observed in transverse ultrasonography images during ankle dorsiflexion and plantar flexion.[8,9] JULY 2020

We first introduced this modality in regional anaesthesia practice for locating the sciatic nerve and demonstrated sciatic nerve movements in a volunteer previously.[10] The principal objective of the study was to verify the significance of sciatic nerve movements in real time ultrasound images induced by ankle dorsiflexion and plantar flexion manoeuvres. We measured the anterior-posterior movements of the sciatic nerve at popliteal fossa and at midthigh region using the built-in calliper of US machine. We also assessed the rotation/lateral movements of the sciatic nerve by using an observer-assigned scoring system.

Material and Methods The current research was designed as a volunteer based prospective cross-over study. Ethics approval was provided by the DumlupÄąnar University Ethical Board (No: 2017-11/8). After obtaining written informed consents, 25 subjects aged between 18 and 38 years were included in this study. Subjects were recruited by asking the operation theatre employees and healthy patients to participate. Subjects were included if they accepted to participate. Exclusion criteria were a history of major trauma or surgery of the leg involving the sciatic nerve at popliteal and thigh regions, having symptoms consistent with sciatic nerve impairment. Participants having a history of neurologic disorder that may cause nervous impairment such as diabetes mellitus or having a disorder of ankle movements were also excluded.

We explained our subjects the procedure and how to make plantar flexion and dorsal flexion manoeuvres before US scanning. The subjects were positioned prone with the lower limbs in neutral position. We provided additional support by placing a pillow under the lower leg to facilitate plantar flexion and dorsiflexion movements (Fig. 1). The ankle was not supported to allow a full joint movement. In all participants, the right leg was imaged.

The Sciatic nerve was scanned by using a 12 MHz linear ultrasound probe (11L; Logiq P6, GE Healthcare, Illinois). The nerve was scanned in transverse plane posteriorly at two separate locations: midthigh and the popliteal fossa. After positioning, the US probe was first placed transversally on the popliteal fossa (Fig. 1a). The transducer was then adjusted to visualize the popliteal artery and vein (Fig. 2). Colour Dop153

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(b)

Figure 1. The position of the volunteer during the ultrasound scan of the popliteal region (a) and the midthigh region (b). The leg was supported with a pillow but the ankle was kept unrestricted to allow a full joint movement. In all participants, the right leg was imaged.

pler was used to facilitate the visualization of the popliteal vessels. The sciatic nerve was identified which is seen as an oval heterogenous structure, just proximal to its separation to tibial and peroneal branches.

When the sciatic nerve is identified and a clear image was obtained, we asked the volunteer to make a maximum plantar flexion manoeuvre and a frozen US image was captured. The distance from the skin to the posterior border of the SN was measured (Fig. 3).

Thereafter, we asked the volunteer to do a maximum ankle dorsiflexion and keep foot at that position.

While the participant was maintaining the maximal ankle dorsiflexion, a frozen ultrasound image was taken and the distance from the skin to the posterior border of the SN was measured. We defined these manoeuvres as active ankle joint movements. The same measurements were performed as described above, while a research assistant was applying the 154

Figure 2. The ultrasound visualization of the popliteal artery, vein and the sciatic nerve at popliteal region.

Figure 3. The ultrasound image of the skin-to-nerve measurement and sciatic nerve diameters at midthigh region.

ankle dorsiflexion and plantarflexion manoeuvres by hand. The latter manoeuvres were defined as passive ankle joint movements.

Thereafter, the sciatic nerve was scanned by following up to the midthigh level (Fig. 1b) and identified again where it was visualized between adductor magnus, semitendinosus/semimembranosus and biceps femoris muscles. The skin-to-nerve distances were consecutively measured as described above at midthigh level during active and passive ankle dorsiflexion and plantar flexion manoeuvres. The nerve movement was defined as the difference of the skinto-nerve distances at maximum dorsiflexion and maximum plantar flexion.

The quality of lateral/rotation sciatic nerve movements was graded according to a 5-point scale during active and passive ankle movements. A score was assigned by the observer to the dynamic (real-time) JULY 2020

Ultrasound detection of sciatic nerve movements to identify location

Table 1. Summary of participants’ characteristics

Age (year) Gender (male, female)

Mean±SD 29.25±11.05 (22,2)

Weight (kg)

79.50±16.57

Height (m)

1.75±0.09

BMI (kg/m2) 26.01±5.51 SD: Standard deviation; BMI: Body mass index. Values presented as mean±standard deviation and numbers (n=24).

Table 2. Measurements of the transverse (antero-posterior) nerve movement in different conditions (n=24) Ankle movement Induced by consecutive active dorsiflexion and plantar flexion (cm) Induced by consecutive passive dorsiflexion and plantar flexion (cm)

Popliteal Midthigh

p

0.32

0.11

0.003

0.23

0.01

<0.001

rotation and lateral movements of the SN (video supplemental). A score of 1was defined as excellent movement observed and the nerve can be clearly distinguished from surrounding structures with the movement. A score of 2 was defined as a good movement of the nerve and the nerve is fairly distinguishable from surrounding tissues. A score of 3 was fair movement but the sciatic nerve is still distinguishable from surrounding tissues. 4 was very little movement is observed and the nerve is very hard to distinguish from the surrounding tissues. A score of 5 was no movements of sciatic nerve observed and the nerve is undistinguishable from surrounding tissues.

among variables were calculated by using Pearson correlation analysis. Normally distributed continuous dependent variables were analysed by paired t test. Nonnormally distributed variables were compared with Mann Whitney U test for independent groups, Wilcoxon test was used for dependent two groups and Friedman analysis were utilized for repeated measures. Spearman correlation analysis was applied to determine correlations among nonnormally distributed variables. Chi-square analyses were used for categorical variables. p value less than 0.05 was accepted significant. All data analyses were calculated by using PASW Statistics 18.

The anteroposterior and lateral diameters of the sciatic nerve were also measured at neutral position. All images were taken by the same sonographer (O.B) who was blinded to all ultrasound measurements.

The sonographic measurements were performed by another researcher (M.Y) who was blinded to the ankle movements and the measurement sites. The measurements were recorded by another research assistant to the follow-up form manually. A blinded researcher (A.M) assessed the results of the study and calculated the differences between the measurements. The significance of the nerve movement was assessed by comparing the skin-to-nerve distance during maximum ankle dorsiflexion with the skin-to-nerve distance during maximum ankle plantar flexion.

Results

Statistical analysis Continuous variables were summarized with n (sample size), mean and standard deviation; categorical variables were summarized with n (sample size), median and 25th 75th percentiles. Normally distributed continuous variables were compared between groups using student t test and the correlations JULY 2020

25 participants successfully completed the study.

One participant was excluded from the study due to missing data. Demographic characteristics of the participants were summarized in Table 1.

At the popliteal region, the antero-posterior nerve movement was found 0.32 cm during the active manoeuvres and 0.23 cm during the passive manoeuvres. With respect to the active and passive movements, there was a significant sciatic nerve movement at popliteal region induced by ankle dorsiflexion and plantar flexion (p<0.001).

At the midthigh region, the nerve movement was found 0.11 cm during the active manoeuvres and 0.01 cm during the passive manoeuvres. With respect to the active and passive movements, there was a significant sciatic nerve movement induced by ankle dorsiflexion and plantar flexion (p<0.001) (Table 2).

The movement of the sciatic nerve observed at the popliteal region was significantly superior than the 155

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14 10 10

10 8 6

12

At the popliteal region, induced by passive ankle joint movements; excellent quality of sciatic nerve movement was observed in 12 of subjects (50%), good quality of the sciatic nerve was observed in 10 subjects (41.7%). Ultrasonic visualization of the SN movement was fair in 1 subject and was poor in 1 subject (Fig. 4).

At the midthigh region, induced by active ankle joint movements; Excellent quality of sciatic nerve movement was observed in 2 subjects (8,3%), good quality of the sciatic nerve was observed in 9 subjects (37.5%). Ultrasonic visualization of the SN was fair in 11 subjects and was poor in 2 subjects.

At the midthigh region, induced by passive ankle joint movements; Excellent quality of the sciatic nerve movement was observed in 3 of subjects (12.5%), good quality of the sciatic nerve movement was observed in 6 subjects (25%). Ultrasonic visual-

Active ankle joint maneuver

11 11

10

9

Passive ankle joint maneuver

8 6

4 2 0

2

4

3

2 0 0

Excellent

At the popliteal region, induced by active ankle joint movements; excellent quality of sciatic nerve movement was observed in 14 of subjects (58.3%), good quality of the sciatic nerve was observed in 10 subjects (41.7%).

No movement

Figure 4. Number of patients categorized according to the sciatic nerve movement at popliteal region.

6

All skin-to-nerve distances at popliteal and midthigh levels during active and passive ankle joint movements and p values were summarized in Table 3.

0 0

No movement

midthigh region induced by active (p=0.003) and passive (p<0.001) ankle joint manoeuvres (Table 2).

0 1 Poor

3.20±0.74 3.21±0.74 <0.001**

0 1

Poor

1.10±0.44 1.33±0.52 <0.001*

0

Good

3.28±0.83 3.39±0.72

Fair

4 2

1.13±0.47 1.45±0.53

*One Way Repeated Measures Analysis of Variance; **Friedman Repeated Measures Analysis of Variance on Ranks.

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Passive ankle joint maneuver

12

12

Good

Active manoeuvres Maximum dorsiflexion Maximum plantar flexion Passive manoeuvres Maximum dorsiflexion Maximum plantar flexion p value

Popliteal Midthigh region region

14

Excellent

Ankle movement

16

Fair

Table 3. Values of skin-to-nerve distances (expressed as centimetre) during active and passive ankle joint movements (mean±standard deviation) (n=24)

Figure 5. Number of patients categorized according to the sciatic nerve movement at midthigh region.

ization of the SN movement was fair in 11 subjects and was poor in 4 subjects (Fig. 5).

The nerve was mostly observed as an oval heterogenous structure, hyperechogenic connective tissue and multiple hypoechogenic dots (representing the nerve fibres), with 0.65±0.15 cm in anteroposterior width and 0.95±0.17 cm in medial-to-lateral width at popliteal region. At the midthigh region, the SN was measured as 0.71±0.17 cm in anteroposterior width and 1.25±0.19 cm in medial-to-lateral width.

Discussion Main findings of our study indicate that a significant movement of the sciatic nerve is observed under ultrasonography visualization in transverse images, induced by ankle plantar flexion and dorsiflexion at both popliteal and midthigh regions. This is the first study in the literature that report the use of ultrasonographic visualization of the sciatic nerve moveJULY 2020

Ultrasound detection of sciatic nerve movements to identify location

ment to recognize and locate the sciatic nerve. Up to date, various methods have been described to facilitate the identification of the sciatic nerve to use in ultrasound guided sciatic nerve blocks. These methods include using the anatomical landmarks of bones, neurostimulator assistance along with ultrasound guidance and identifying surrounding muscles and fascial planes using ultrasound at the block site.[11–13] One other method offered for facilitating the nerve localization is “figure of four” positioning of the legs.

[14] Scanning the nerve up along its course may also be helpful.[2] Ultrasonographic scanning of vessels close to the sciatic nerve may help to facilitate SN location. Detecting the doppler flow of the internal pudendal artery and inferior gluteal vessels, at the gluteal region was also reported to identify the SN.[1] As there is not any vascular structure in the sub-gluteal or midthigh region, scanning a vessel close to the SN cannot be offered at these locations.[2,4] Detection of the arteria comitans was also reported as a method to facilitate the ultrasound localization of the sciatic nerve in the gluteal and thigh regions where the arteria comitans accompanies the sciatic nerve.[4] Our method is a novel technique different from these for facilitating the localization of the SN which can be used at various levels of the leg. As no additional tool other than ultrasound is needed, we find this an easy method that is applied during the block performance.

Both active (performed by the patient) or passive (performed by an assistant) ankle joint movements would help to move the sciatic nerve and facilitate its location. A better SN movement was observed at the popliteal region in our study. However, a good nerve movement was also found at the midthigh of the leg.

This may be due to more superficial location of the SN at popliteal region than the midthigh.

It is important to achieve a circumferential spread of local anesthetics around the tibial and peroneal nerves which was also defined as: “coin sign”.[15,16] However, injection of small amounts of local anaesthetic within the para-neural sheath leads to more successful blocks than performing a perineural injection.[17,18] Intraneural technique needs a precise location of the SN along with the needle tip during the injection. Our method may help to locate the SN precisely during the block procedure when intraneural injection technique is used.

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A secondary objective of this study was to determine the real-time observed movement of the SN in dynamic US images. We used an observer assigned scoring system to assess this. We observed a good sciatic nerve movement according to our observer grading scores (video supplement). As ultrasonography is a dynamic procedure, real-time observation of the SN movement may be a better indicator and static ultrasound images may not reflect this aspect of the sciatic nerve movement. We recommend the performers to refer to the dynamic US visualization and focus on real-time US scanning when using our method.

The volunteer-based nature of the study may limit the ability of evaluating the effect of SN movements on block success. Our aim was to demonstrate the movements of the SN in a practical manner to help its location. The ease of visualizing the movements of the sciatic nerve at popliteal and midthigh levels would suggest an advantage in performing the injections at these levels and this may potentially improve efficacy of sciatic nerve blocks. A future clinical prospective randomized study is needed to prove its effect on the block success. One limitation of our technique may be the difficulty of application in trauma patients with possible constraint of ankle joint and sciatic nerve movements.

In conclusion, a good quality of sciatic nerve movement can be observed in transverse plane at the popliteal and midthigh regions under real time ultrasound imaging. Both active and passive dorsiflexion and plantar-flexion foot manoeuvres lead to apparent movements of the sciatic nerve which is easily observed under ultrasound visualization. This is a novel, simple and successful sonographic technique to identify the sciatic nerve at popliteal and midthigh regions which may offer an additional tool to determine the location of the sciatic nerve during sciatic nerve blocks.

Ethics Committee Approval: Ethics approval was provided by the Dumlupınar University Ethical Board (date: 25.10.2017, number: 2017-11/8).

Conflict-of-interest issues regarding the authorship or article: None declared.

Peer-rewiew: Externally peer-reviewed.

Financial Disclosure: The authors declared that this study has received no financial support.

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doi: 10.5505/agri.2018.68552

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CASE REPORT

Frontal recess osteoma causing severe headache Şiddetli başağrısına neden olan frontal reses osteomu Ceyhun AKSAKAL Summary Frontal sinus osteomas are benign and well-defined masses that may cause various symptoms when they press on the surrounding tissues. Paranasal sinus osteoma is seen as a well-defined mass showing high opacity in Computed tomography. In this case study, we presented here a 53-year-old frontal recess osteoma with severe headache filling the left frontal recess in the context of the literature.

Keywords: Computed tomography; headache; osteoma.

Özet Frontal reses osteomları benign, iyi sınırlı, çevre dokulara baskı yaptığında farklı semptomlara neden olan olan kitlelerdir. Paranazal sinüs osteomları tomografide yüksek opasifiye, iyi sınırlı kitle olarak görülürler. Biz 53 yaşında sol frontal resesi dolduran osteomu olan ve şiddetli baş ağrısı olan hastayı literatür eşliğinde sunduk.

Anahtar sözcükler: Komputerize tomografi; baş ağrısı; osteom.

Introduction Frontal sinus osteomas are often asymptomatic, but slowly growing, benign tumours that can cause different symptoms when they compress the surrounding tissue.[1] Disturbances in the frontal sinus drainage may cause symptoms of sinusitis, as well as unilateral localised or bilateral headache.[2] Paranasal sinus computed tomography (CT) is the most useful in the diagnosis. The type of surgery is determined according to the size of the mass and the relationship with the surrounding tissues. Surgery is open, or endoscopic, or a combination of the two methods is used.

We present a case of a frontal recess osteoma causing severe headache in the context of the literature.

Case Report A 53-year-old male patient presented with severe pain in the left side and complaints in the left eye at the outpatient clinic. The patient had previously

received 10 days of antibiotic treatment in other centres. A paranasal sinus CT scan showed a mass of 17×11 mm in diameter, occupying the lower third of the frontal sinus, filling the left frontal recess and disrupting the sinus drainage (Fig. 1). The septum deviations that prevented reaching the mass on the left side were intervened. A mass filling the frontal recess and extending the frontal sinus was mobilised and removed in one piece (Fig. 2, 3). The mass was in contact with the lamina papyracea and the anterior headbase. No defect was observed in the lamina papyracea. However, there was a defect of 1×1 cm in the anterior osseous area of the skull base. However, no cerebrospinal fluid fistula was detected. The patient was followed up for 4 days in the clinic. During this period, he was given antibiotic treatment of 1 g ceftriaxone three times a day The patient was discharged on the 4th day. At the 5th-month follow-up, the patient’s symptoms completely disappeared and no problems were observed.

The current affiliation of the author: Department of Otorhinolaryngology, Gaziosmanpaşa University Faculty of Medicine, Tokat, Turkey Department of Otorhinolaryngology, Tokat State Hospital, Tokat, Turkey Submitted: 14.01.2018 Accepted after revision: 18.06.2018 Available online date: 01.10.2018

Correspondence: Dr. Ceyhun Aksakal. Tokat Devlet Hastanesi, Kulak Burun Boğaz Polikliniği, 60100 Tokat, Turkey.

Phone: +90 - 356 - 212 95 00 e-mail: aksakalceyhun@gmail.com © 2020 Turkish Society of Algology

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Figure 3. Post-operative picture of the mass.

(b)

Figure 1. (a) Coronal section of computerised tomography scan of the patient. Osteoma (black arrow), nasal septum (white arrowhead). (b) Sagittal section. Osteoma (black arrow), anterior skull base (oblique black line).

Figure 2. Intraoperative endoscopic view of the mass. Osteoma (black arrow), nasal septum (black arrowheads).

Discussion Osteomas are benign, slowly growing, well-limited tumours of the paranasal sinuses. They are primarily observed in the frontal sinuses, followed by the 160

ethmoid sinuses.[3] There is a male predominance among the affected populations.[4] Our patient was a 53-year-old male patient. Osteomas are often incidentally detected to be asymptomatic. Paranasal sinus CT is the gold standard in the diagnosis. CT shows a radiopaque mass with well-defined borders, which can cause various symptoms depending on the size of the lesion and the mass. Headache is observed especially in case of frontal osteomas. However, frontal osteomas are incidentally detected simultaneously in non-symptomatic headaches. Radiological imaging is important in this context. In addition, frontal osteomas must be considered in the differential diagnosis of patients applying to the neurology clinic with headache.[5] Obliteration of the frontal recess can cause sinusitis symptoms and severe headache by disrupting the sinus drainage. In our case, the osteoma that obstructed the frontal recess was under pressure in the lamina papyracea. There was severe pain on the left side of the forehead and numbness in the left eye.

The treatment for symptomatic frontal sinus osteomas is surgery. The type of surgery is determined based on the size and location of the osteoma. According to Chiu et alâ&#x20AC;&#x2122;s[6] classification, the frontal osteomas are differentiated based on the occupation of the frontal recess. Grade 1 and 2 tumours are treated using an open approach, whereas grade 3 and 4 tumours can be treated by the endoscopic method. Our case was grade 1, and an endoscopic approach was planned.

In our case, we osteotomised the osteomas by excising from the surrounding tissues. SieĹ&#x203A;kiewicz A.[7] applied endoscopic approach to all the eight frontal osteoma series and obtained complete cure in all the patients.[8] In another series of 60 patients reported JULY 2020

Frontal recess osteoma causing severe headache

by Turri-Zanoni et al.,[9] the authors had applied endoscopic approach to 31 patients, combined approach to 25 patients and open approach to 4 patients, with no long-term recurrences being observed during the periodic follow-ups.[10] It has been emphasised that the endoscopic approach has low post-operative morbidity in these series. In our case, we performed endoscopic excision of the frontal recess and filling osteoma that prevented the sinus drainage.

In conclusion, frontal recess osteomas can lead to different symptoms depending on the region where they are pressed, and high success rates can be obtained using an appropriate surgical treatment.

Informed Consent: Written informed consent was obtained from the patient for the publication of the case report and the accompanying images.

Conflict-of-interest issues regarding the authorship or article: None declared.

Peer-rewiew: Externally peer-reviewed.

References 1. Huang HM, Liu CM, Lin KN, Chen HT. Giant ethmoid osteoma with orbital extension, a nasoendoscopic approach using an intranasal drill. Laryngoscope 2001;111(3):430–2.

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2. Buyuklu F, Akdogan MV, Ozer C, Cakmak O. Growth characteristics and clinical manifestations of the paranasal sinus osteomas. Otolaryngol Head Neck Surg 2011;145(2):319– 23.

3. Cheng KJ, Wang SQ, Lin L. Giant osteomas of the ethmoid and frontal sinuses: Clinical characteristics and review of the literature. Oncol Lett 2013;5(5):1724–30.

4. Selva D, White VA, O’Connell JX, Rootman J. Primary bone tumors of the orbit. Surv Ophthalmol 2004;49(3):328–42.

5. Ata N, Tezer MS, Koç E, Övet G, Erdur Ö. Large Frontoorbital Osteoma Causing Ptosis. J Craniofac Surg 2017;28(1):e17– e18.

6. Chiu AG, Schipor I, Cohen NA, Kennedy DW, Palmer JN. Surgical decisions in the management of frontal sinus osteomas. Am J Rhinol 2005;19(2):191–7.

7. Sieśkiewicz A, Lyson T, Piszczatowski B, Rogowski M. Endoscopic treatment of adversely located osteomas of the frontal sinus. Ann Otol Rhinol Laryngol 2012;121(8):503–9.

8. Ledderose GJ, Betz CS, Stelter K, Leunig A. Surgical management of osteomas of the frontal recess and sinus: extending the limits of the endoscopic approach. Eur Arch Otorhinolaryngol 2011;268(4):525–32.

9. Turri-Zanoni M, Dallan I, Terranova P, Battaglia P, Karligkiotis A, Bignami M, et al. Frontoethmoidal and intraorbital osteomas: exploring the limits of the endoscopic approach.

Arch Otolaryngol Head Neck Surg 2012;138(5):498–504.

10. Bolzoni Villaret A, Schreiber A, Esposito I, Nicolai P. Endoscopic ultrasonic curette-assisted removal of frontal osteomas. Acta Otorhinolaryngol Ital. 2014;34(3):205–8.

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OLGU SUNUMU / CASE REPORT

Erişkin hemofili hastasında ultrason rehberliğinde penil blok ile cerrahi anestezi Surgical anesthesia using ultrasound-guided penile nerve block for adult hemophilia patient Sevim CESUR,

Yavuz GÜRKAN,

Neşe TÜRKYILMAZ,

Alparslan KUŞ,

Can AKSU

Özet 22 yaşında, hemofili A hastalığı olan ASA II erkek hastaya sünnet cerrahisi için cerrahi anestezi sağlamak amaçlı Ultrason rehberliğinde Dorsal Penil Sinir Bloğu (DPNB) uygulandı. DPNB için 20 ml %0,25 bupivakain kullanıldı. Cerrahi, blok ile sorunsuz olarak tamamlandı. Hastanın ilk 24 saat içinde ağrısı olmadı.

Anahtar sözcükler: Dorsal penil sinir bloğu; hemofili; sünnet cerrahisi.

Summary Ultrasound-Guided Dorsal Penile Nerve (DPNB) Block was performed to provide surgical anesthesia for a 22 years old ASA II patient who had hemophilia A and was undergoing circumcision surgery. 20 ml of 0.25% bupivacaine was used for the DPNB. Surgery was completed under block without complication. Twenty-four hours of the analgesia was provided following surgery.

Keywords: Dorsal penile nerve block; hemophilia; circumcision surgery.

Giriş Sünnet, pek çok dini ve kültürel gerekçelerle yaygın olarak uygulanan cerrahi bir işlemdir. Genellikle çocukluk çağında gerçekleştirilen bu işlem çeşitli tıbbi zorluklar sebebiyle erişkinlik döneminde de yapılabilir.

Penil cerrahi için pediyatrik yada yetişkin hasta grubunda hastanın tıbbi durum ve tercihlerine göre genel anestezi, epidural/spinal gibi nöroaksiyal bloklar uygulanabilir. Ayrıca pudental sinir bloğu veya penil blok gibi rejyonal teknikler ile de perioperatif dönemde anestezi ve/veya analjezi sağlanabilir.[1] Penil blok uzun yıllardır etkin bir biçimde kullanılan bir rejyonal anestezi tekniğidir.[2,3] US rehberliğinde Dorsal Penil Sinir Bloğu (DPNB) ise Gurkan ve ark. tarafından erişkin hastalarda tarif edilmiştir.[4]

Olgumuzda erişkin hastamızın US rehberliğinde DPNB ile anestezi ve analjezi yönetimi uygulamamızı paylaşmak istedik.

Olgu Sunumu 22 yaşında, 75 kg, Hemofili A tanısı olan ASA II erkek hastaya sünnet operasyonu planlandı. Genel anestezi tercih etmeyen hasta DPNB uygulaması için bilgilendirildi. Derlenme ünitesinde 22 G damar yolu açıldıktan sonra premedikasyon 0.03 mg/ kg intravenöz (i.v.) midazolam ile sağlandı. Ameliyat odasına alınan hastaya US rehberliğinde DPNB blok yapıldı. Blok symphysis pubis üzerine sagittal olarak yerleştirilmiş yüksek frekanslı lineer prob kullanılarak yapıldı. Sagittal düzlem üzerinde penil şaft, korpus kavernosum, pubik kemik ve skarpa fasyası görüldü (Şekil 1). Gerçek zamanlı US rehberliğinde, 50 mm boyutundaki blok iğnesi (Ultraplex, 22G; B. Braun, Melsungen, Almanya) out-of-plane teknikle skarpa

Kocaeli Üniversitesi Tıp Fakültesi, Anestezi ve Reanimasyon Anabilim Dalı, Kocaeli Department of Anesthesia and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey Başvuru tarihi (Submitted) 07.11.2017 Düzeltme sonrası kabul tarihi (Accepted after revision) 11.04.2018 Online yayımlanma tarihi (Available online date) 10.10.2018

İletişim (Correspondence): Dr. Sevim Cesur. Kocaeli Üniversitesi Tıp Fakültesi Hastanesi, Umuttepe Kampüsü, 1. Kat, Ameliyathane, Kocaeli, Turkey.

Tel (Phone): +90 - 262 - 303 82 48 e-posta (e-mail): svmcsr@gmail.com © 2020 Türk Algoloji Derneği

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DPNB uzun yıllardır özellikle çocuklarda sünnet operasyonlarında tercih edilen bir tekniktir.[2] DPNB kör teknikle supin pozisyondaki hastada penis köküne saat 10 ve 2 poziyonuna infiltasyonla uygulanabilir.

US eşliğinde uygulanması ile özellikle olası komplikasyonlar (damar ponksiyonu, üretral yaralanma, hematom) açısından kör tekniğe oranla daha güvenli bir yöntemdir.[8]

Şekil 1. Penil blok.

fasyasını geçilerek uygulandı. Lokal anestezik olarak 20 ml %0,25 bupivakain uygulandı.

Blok işleminden sonra cerrahi ekip tarafından 10 ml %1 lidokain ile ventral infiltrasyon uygulandı. Blok işleminden sonra 5 dk aralıklarla hastaya buz aküsü ile soğuk ve sıcak duyu kontrolü ve pinprick testi ile dokunma ve ağrı duyusu kontrolü yapıldı. Yaklaşık 20 dk. sonra operasyona başlandı. Operasyon 30 dk. sürdü ve herhangi bir komplikasyon gelişmeden tamamlandı. Peroperatif ağrısı olmayan hasta derlenme ünitesine alındı. Cerrahi servise çıkarılan hastanın ilk 24 saati analjezik ihtiyacı olmadan ağrısız olarak geçirdi.

Tartışma Hemofili A Faktör VIII eksikliği sonucunda gelişen nadir bir kalıtsal kanama bozukluğudur.[5] Hemofili A tanılı hastaların cerrahi işlem öncesi hazırlıkları, anestezi yönetimi ve postoperatif izlemi ayrıcalıklıdır. Yeterli faktör düzeyinin sağlanması ile cerrahi işlemler güvenli bir şekilde yapılabilir. Faktör verilme süresi, dozu hemofilinin şiddetine ve cerrahi işlemin tipine bağlıdır. Hemofili hastalarında cerrahi girişimler kanama risklerine göre majör ve minör olarak ikiye ayrılır. Sünnet majör cerrahi girişimler arasında sayılmaktadır.[5] Genel anestezi uygulanmasını istemeyen hastamızda potansiyel kanama ve hematom riski nedeni ile spinal ve epidural anestezi gibi santral nöroaksiyal bloklar tercih edilmemiştir. Periferik sinir blokları ise perioperatif dönemde güvenli Faktör VIII seviyesinin korunması şartıyla orta-şiddetli hemofili hastalarında cerrahi ve ağrı kontrolü için uygulanabilir.[6,7]

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Bu olguda erişkin hastamızda US rehberliğinde DPNB uygulanarak sünnet cerrahisi için anestezi başarıyla sağlandı. Tıbbi nedenlerle genel anestezi ya da santral blokların tercih edilmediği erişkin hastalarda DPNB cerrahi anestezi sağlamakta kullanılabilecek bir yöntem olabilir.

Hasta Onamı: Olgu sunumunun ve beraberindeki görüntünün yayınlanması için yazılı bilgilendirilmiş onam alındı.

Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması (conflict of interest) yoktur.

Hakem değerlendirmesi: Dış bağımsız.

Kaynaklar 1. Metzelder ML, Kuebler JF, Glueer S, Suempelmann R, Ure BM, Petersen C. Penile block is associated with less urinary retention than caudal anesthesia in distal hypospadia repair in children. World J Urol 2010;28(1):87–91.

2. Bateman DV. An alternative block for the relief of pain of circumcision. Anaesthesia 1975;30:1.

3. Kirya C, Werthmann MW Jr. Neonatal circumcision and penile dorsal nerve block--a painless procedure. J Pediatr 1978;92(6):998–1000.

4. Gürkan Y, Kuş A, Aksu C, Çiftçi S, Çulha M, Pandin P. Ultrasonography-guided penile block for adult penile surgery.

Can J Anaesth 2016;63(6):780–1.

5. Türk Hematoloji Derneği. Hemofili Tanı ve Tedavi Kılavuzu.

Available at: http://www.thd.org.tr/thdData/userfiles/file/ kilavuz-1.pdf. 2011.

6. Sripada R, Reyes JJ, Sun R. Peripheral nerve blocks for intraoperative management in patients with hemophilia A. J Clin Anesth 2009;21(2):120–3.

7. Gentili ME, Poisson N, Guezennec D, Candelier G, Samama CM. Combination of ultrasonographic supraclavicular block and general anaesthesia for arthroscopic shoulder surgery in a patient with haemophilia A. Eur J Anaesthesiol 2014;31(11):649–50.

8. Fontaine P, Dittberner D, Scheltema KE. The safety of dorsal penile nerve block for neonatal circumcision. J Fam Pract 1994;39(3):243–8.

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CASE REPORT

Fluoroscopically guided transforaminal epidural catheterization of the ankylosing spondylitis Ankilozan spondilitli olguda floroskopi eşliğinde transforaminal epidural kateter Sema ŞANAL BAŞ,1

Sacit Mehmet GÜLEÇ2

Summary Ankylosing spondylitis (AS) is a chronic, progressive, autoimmune collagen tissue disease characterized by inflammation and lower back pain. General anesthesia may pose a high risk in the AS due to intubation difficulty, as well as affected respiratory and cardiovascular organs. In cases of involvement of the vertebrae, neuraxial anesthesia may be difficult or even impossible.

In this article, we discuss a case of AS that received a successful an epidural catheter was placed using a transforaminal route under C-arm fluoroscopy guidance for total hip replacement surgery, which was difficult due to intubation and an interlaminar neuraxial anesthesia.

Keywords: Ankylosing spondylitis; epidural; fluoroscopy; transforaminal.

Özet Ankilozan spondilit (AS), enflamatuvar bel ağrısı ve sakroileit ile karakterize kronik, progresif ve otoimmün bir kollajen doku hastalığıdır. Bu hasta grubunda, zor hava yolunun yanında solunum, kardiyovasküler organ tutulumları nedeniyle genel anestezi uygulaması yüksek riskli olabilir. Vertabra tutulumu olduğunda ise nöroaksiyel blok zor ya da imkansız hale gelebilir. Total kalça protezi yapılan, AS nedeniyle entübasyon güçlüğü olan ve interlaminar nöroaksiyel blok imkansız gibi görünen bir olguda floroskopi eşliğinde transforaminal yoldan epidural kateter yerleştirilerek yapılan başarılı bir epidural anestezi uygulamasını tartıştık.

Anahtar sözcükler: Ankilozan spondilit; epidural; floroskopi; transforaminal.

Introduction Ankylosing spondylitis (AS) is a chronic, progressive and autoimmune collagen tissue disease. The inflammation in the joints causes progressive degenerative osteoarthritis.[1] In this article, we discuss a case of AS that received a successful epidural catheterization and anesthesia in for total hip replacement surgery, which was made difficult due to intubation and an interlaminar neuroaxial anesthesia via transforaminal route under fluoroscopy guidance. To our knowledge, there is no such report in the literature.

Case Report A fifty year old male patient, weighing 85 kg and 167 cm tall, presented to the orthopedics outpatient clinic. He was diagnosed with coxarthrosis of the left joint, and total hip replacement surgery was planned.

The patient had a history of ankylosing spondylitis for 20 years. He developed congestive heart failure, restrictive type lung disease, and uveitis at the left eye during the previous year. In his physical examination, there was postural deformity, and his left hip joint had a 30-degree flexion posture with no active or passive motion possible. His muscle strength at his bilateral lower extremities was 4/5. In the head and neck examination, he had impaired vision in his left eye; mouth opening range was 2-cm; thyromental distance measured 4-cm, sternomental distance measured 6-cm; and there was limited motion in his extension (40 degrees) and flexion (10 degrees) of the neck. The Mallampati score was assessed as class III. Vertebral radiogram revealed squaring of vertebral bodies, and bamboo spine appearance and due to syndesmophytes (Figure 1). Written informed consent was obtained from the patient after that the pa-

Department of Anesthesiology and Reanimation, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey Division of Algology, Department of Anesthesiology and Reanimation, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey

1 2

Submitted: 08.02.2018 Accepted after revision: 11.04.2018 Available online date: 04.10.2018

Correspondence: Dr. Sema Şanal Baş. Meşelik Kampüsü, Eskişehir Osmangazi Üniversitesi Tıp Fakültesi Hastanesi, Anesteziyoloji Sekreterliği, Odunpazarı, 26480 Eskişehir, Turkey.

Phone: +90 - 222 - 239 29 79 / 5007 e-mail: drsemasa@gmail.com © 2020 Turkish Society of Algology

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Figure 2. Epidural cathaterLateral fluoroscopic images.

Figure 1. Patient vertebral radiogram.

tient was taken to the operating. Premedication was not administered. Before anesthesia administration, equipment was checked, including a LMA fastrach, gum elastic bougie, a videolaryngoscopy, a tracheostomy tray. We decided to the patient of epidural catheterization via fluoroscopic guided (Plan A). Accidental dural puncture could be recognized with cerebrospinal fluid, we would place the catheter into the subarachnoid space for continuous spinal anesthesia (Plan B). We would performed the general anesthesia if the administration of epidural anesthesia could been respiratory insufficiency or failed neuroaxial block (Plan C).

The patient was positioned prone, a betadine-based solution is spread over the skin in circular fashion, and sterile drapes applied. After under C-arm-fluoroscopy guidance, an 18-gauge Tuohy needle was advanced through the lumbar (L) 4-5 space with a 20 degree oblique angle until the intervertebral foramen. Confirming the position of the tip of the needle at intervertebral foramen using anteroposterior (AP) and lateral fluoroscopic images, an epidural catheter was placed in the epidural space by inserting through a Tuohy needle.

After negative aspiration for cerebrospinal fluid and blood, non-ionic contrast material iohexol (Omnipaque) was injected (3 ml) from the catheter in fractions, and the catheter was confirmed to be in the epidural space using AP and lateral fluoroscopic images (Figure 2). The catheter was advanced to the JULY 2020

upper part of L3 vertebra level. The patient was then positioned supine, and 3 ml (lidocaine 1.5% and 1:200,000 epinephrine) was injected as epidural test dose. Following confirmation of the catheterâ&#x20AC;&#x2122;s place, 12 ml of a 0.5% isobaric bupivacaine was injected in fractions. When the blockade level reached T8, the patient was positioned properly and the operation was initiated. The operation lasted 4 hours. The patient required a local anesthetic dose twice until the end of the operation, and a total of 20 ml of a 0.5% isobaric bupivacaine was administered during the operation. During 2 postoperative days, the patientcontrolled epidural analgesia was continued. On the 6th day, the patient was discharged from the orthopedics ward with recommendations.

Discussion General anesthesia may pose high risk in patients with AS because of the known respiratory problems, cardiovascular organ involvement, and difficulty with intubation.[1,2] Although neuroaxial anesthesia seems to be a great alternative, narrow epidural space and ossifications in ligamentum flavum can cause application challenges and even make the blockade impossible.[1â&#x20AC;&#x201C;3] We describe a case of epidural catheterization via transforaminal route under fluoroscopy guidance from ankylosing spondylitis undergoing total hip replacement surgery.

Technical difficulties are also increase the risk of complications, including spinal hematoma. Epidural catheter placement may be technically difficult due to restricted flexion of the lumbar spine and ossifica165

A RI PAIN tion of interspinous ligaments and it often leads to complete failure. Neuroaxial blocks are technically challenging and local anesthetic toxicity due to intravascular injection or an unpredictable level of anesthesia for epidural injection.[4] Fluoroscopically guided transforaminal epidural steroid injection is administered for treatment of a chronic radicular lower limb pain.[5,6] Major and minor complications regarding transforaminal epidural steroid injection applications were reported in the literature.

Transforaminal injection of minor and major complications ınclude vasovagal reaction, dural puncture, intradiscal injection, infections, bleeding (epidural hematoma, spinal hematoma). There are also neurological complications such as stroke, spinal cord injury, arachnoiditis which are associated with epidural steroid injection not transforaminal technique.[7] However, there is no data on utilization of transforaminal epidural catheterization for surgical purposes under fluoroscopy guidance. Only the one case report, 23 gauge quinkeys spinal needle was inserted under fluoroscopically guided transforaminal single shot epidural injection for ureteroscopic stone removal.[4] We used to achieve in patients with AS by epidural catheterization via transforaminal route under fluoroscopy guidance and a successful anesthesia management during the surgery.

Anatomical changes that occur in AS, such as fusion of lumbar vertebrae, narrow interlaminar arena and calcification of posterior longitudinal ligament, adequate mouth opening.[8–10] These changes can lead difficulty management of airway and epidural or spinal anesthesia so that alternative managements can used the patient. Peripheral nerve blocks have performed successfully of guided ultrasound (US) and fluoroscopy. But US guided is not gold standard for deeper structures and spinal procedure. And ıt can performed with guided computed tomography or fluoroscopic performs the gold standard in the lumbar spine.[11–14] So we decided to perform epidural catheterization via guided fluoroscopy and management of epidural anesthesia was successful.

Intubation assist methods such as awake fiberoptic intubation and video laryngoscopy can be used to overcome the difficulties in patients performed 166

general anesthesia with AS.[9,12–14] According to one previous report, they could not perform neuroaxial anesthesia in one case due to ossification of the ligamentum flavum in the lumbar vertebrae and narrowing of the interlaminar entry area. Ankylosing spondylitis can lead to difficulty in neuroaxial anesthesia to change of ossified vertebral column and narrowed intervertebral spaces. Narrowing of interlaminar area can lead to traumatic complication such as difficult transforaminal catheterization, direct vascular damage secondary to needle replacement, and nervous root injury irritation.[10] We did not have any technical difficulties or any complication in our case.

In conclusion, we showed that a successful neuroaxial anesthesia can be relatively safe alternative in patients with AS by epidural catheterization via transforaminal route under fluoroscopy guidance.

Therefore, it should be performed by an experienced physician or under the guidance of an experienced technician and radiologic imaging must be used. It should be kept in mind that management of a case of ankylosing spondylitis can be very challenging as the airway and the central neuraxial blockade are extremely difficult. The anesthesia management should be planned an alternative option for airway management and fluoroscopy may lead to predictable success in the AS of transforaminal epidural catheterization.

Informed Consent: Written informed consent was obtained from the patient for the publication of the case report and the accompanying images.

Conflict-of-interest issues regarding the authorship or article: None of the authors had conflicts of interest in relation to this study or was provided funding by the manufacturer.

Peer-rewiew: Externally peer-reviewed.

References 1. Chen L, Liu J, Yang J, Zhang Y, Liu Y. Combined Fascia Iliaca and Sciatic Nerve Block for Hip Surgery in the Presence of Severe Ankylosing Spondylitis: A Case-Based Literature Review. Reg Anesth Pain Med 2016;41(2):158–63.

2. Schelew BL, Vaghadia H. Ankylosing spondylitis and neuraxial anaesthesia--a 10 year review. Can J Anaesth 1996;43(1):65–8.

3. Wulf H. Epidural anaesthesia and spinal haematoma. Can J Anaesth 1996;43(12):1260–71.

4. Channabasappa SM, Dharmappa S, Pandurangi R. Fluoroscopy guided transforaminal epidural anesthesia in anky-

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5.

6.

7.

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losing spondylitis. Saudi J Anaesth 2016;10(1):101–3.

Irwin RW, Zuhosky JP, Sullivan WJ, Foye PM, Sable AW, Panagos A. Industrial medicine and acute musculoskeletal rehabilitation. 5. Interventional procedures for work-related lumbar spine conditions. Arch Phys Med Rehabil 2007;88(3 Suppl 1):S22–8.

Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician 2012;15(2):131–40.

Bicket MC, Chakravarthy K, Chang D, Cohen SP. Epidural steroid injections: an updated review on recent trends in safety and complications. Pain Manag 2015;5(2):129–46.

Bajwa SJ, Bajwa SK, Kaur J, Singh BA, Prasad S. Anaesthetic management of a vaginal hysterectomy case with an unanticipated failure of epidural injection due to fused lumbar spine. Int J Appl Basic Med Res 2011;1(1):57–9.

Lili X, Zhiyong H, Jianjun S. A comparison of the GlideScope with the Macintosh laryngoscope for nasotracheal

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intubation in patients with ankylosing spondylitis. J Neurosurg Anesthesiol 2014;26(1):27–31.

10. Hoffman SL, Zaphiratos V, Girard MA, Boucher M, Crochetière C. Failed epidural analgesia in a parturient with advanced ankylosing spondylitis: a novel explanation. Can J Anaesth 2012;59(9):871–4.

11. Korbe S, Udoji EN, Ness TJ, Udoji MA. Ultrasound-guided interventional procedures for chronic pain management.

Pain Manag 2015;5(6):465–82.

12. Leung KH, Chiu KY, Wong YW, Lawmin JC. Case report: Spinal anesthesia by mini-laminotomy for a patient with ankylosing spondylitis who was difficult to anesthetize. Clin Orthop Relat Res 2010;468(12):3415–8.

13. Turgut Balcı Ş, Türköz A, Çınar Ö, Bircan HY, Sekmen Ü. Alternative anaesthetic management in ankylosing spondylitis. Agri 2014;26(4):196–7.

14. Aydeniz A, Akaltun MS, Gür A, Gürsoy S. Coexistence of polymyalgia rheumatica with ankylosing spondylitis: A case report. Agri 2018;30(1):35–7.

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Agri 2020;32(3):168–170

doi: 10.5505/agri.2018.62687

A RI PAIN

OLGU SUNUMU / CASE REPORT

Rejyonel anestezide nadir görülen unutulması durumunda yüksek risk taşıyan bir refleks: Bezold-Jarisch refleksi Rare reflex in regional anesthesia which have a high-risk in case of forgotten: Bezold-Jarisch reflex Fethi AKYOL,1 Kenan EROL,2

Orhan BINICI,2 Özgür ÖZMEN,1 Mahmut Alp KARAHAN2

Evren BÜYÜKFIRAT,2

Özet Bezold-Jarisch refleksi rejyonal anestezi, üst ekstremite sinir blokları ve bazen de genel anestezi sırasında kimyasal veya mekanik reseptörlerle uyarı sonucu hipotansiyon, bradikardi, apne veya kardiyak arrest ile ortaya çıkabilir. Üst ekstremite sinir blokları sırasında daha çok oturur pozisyonda ortaya çıkan bu refleks diğer komplikasyonlar arasında genellikle unutulabilmektedir. Önlemler alındığı ve yeterli kardiyak monitörizasyon yapıldığı takdirde bu refleks neticesinde oluşabilecek komplikasyonların üstesinden gelinebilmektedir. Bu çalışmada sunacağımız vakalarda unutulduğu zaman ciddi komplikasyonlara yol açabilecek bir refleks olan Bezold-Jarisch refleksini hatırlatmak istedik.

Anahtar sözcükler: Bezold-Jarisch refleksi; oturur pozisyon; üst ekstremite sinir blokları.

Summary Bezold-Jarisch reflex is a reflex that may occur during regional anesthesia, upper-extremity blocks and sometimes in general anesthesia, resulting in hypotension, bradycardia, apnea or cardiac arrest elicited by chemical or mechanical receptor stimulations. This reflex mostly occurs in the sitting position during upper-extremity nerve blocks can be forgotten in other complications. The complications that occurred after this reflex can be overcome by taking necessary precautions and providing sufficient cardiac monitorization. In our cases to be presented, we want to remind you of Bezold-Jarisch reflex, which may cause severe complications when forgotten.

Keywords: Bezold-Jarisch reflex; sitting position; upper-extremity blocks.

Giriş Bezold-Jarisch refleksi kimyasal veya mekanik reseptörlerle uyarı sonucu gelişen apne, bradikardi, hipotansiyon ile sonuçlanan bir reflekstir. İlk defa 1867 yılında Bezold tarafından tariflenmiş, sonrasında 1938–1940 yıllarında Jarisch tarafından tanımlanmıştır. Günümüzde ventrikül duvarı gerildiğinde gelişen bradikardi, vazodilatasyon ve hipotansiyon Bezold-Jarisch refleksi olarak adlandırılır.[1,2] Ortostatik pozisyonda, hipovolemide, spinal ve nöroaksiyel anestezi sırasında, interskalen blok altında oturma pozisyonunda ve genel anestezi sırasında ağrı ve

anksiyete sırasında Bezold-Jarisch refleksinin gelişebildiği bilinmektedir.[3] Bu refleks kalp atış hızının beş dakika boyunca 50–30 atım/dk’nın altına veya sistolik arter basıncının 90 mmHg’nin altına düştüğü durum olarak da tanımlanmaktadır.[4] Bu olgu sunumunda; ortopedik cerrahi planlanan iki hastada interskalen blok sonrası Bezold-Jarisch refleksi sebebi ile kardiak arrest gelişimi ele alınacaktır.

Olgu Sunumu Olgu 1 – Seksen dokuz yaşında erkek hasta acil servise travma sonucu humerus şaft kırığı nedeniyle

Erzincan Üniversitesi Tıp Fakültesi, Eğitim ve Araştırma Hastanesi, Anestezi ve Reanimasyon Anabilim Dalı, Erzincan Harran Üniversitesi Tıp Fakültesi, Araştırma ve Uygulama Hastanesi, Anestezi ve Reanimasyon Anabilim Dalı, Şanlıurfa 1 Department of Anesthesia and Reanimation, Erzincan University Faculty of Medicine, Training and Research Hospital, Erzincan, Turkey 2 Department of Anesthesia and Reanimation, Harran University Faculty of Medicine, Research and Practice Hospital, Şanlıurfa, Turkey 1 2

Başvuru tarihi (Submitted) 04.12.2017 Düzeltme sonrası kabul tarihi (Accepted after revision) 21.05.2018 Online yayımlanma tarihi (Available online date) 04.10.2018

İletişim (Correspondence): Dr. Fethi Akyol. Erzincan Üniversitesi Tıp Fakültesi, Eğitim ve Araştırma Hastanesi, Anestezi ve Reanimasyon Anabilim Dalı, Erzincan, Turkey.

Tel (Phone): +90 - 505 - 542 29 92 e-posta (e-mail): fethi24@windowslive.com © 2020 Türk Algoloji Derneği

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Rejyonel anestezide nadir görülen unutulması durumunda yüksek risk taşıyan bir refleks: Bezold-Jarisch refleksi

başvurdu. Hastanın öyküsünde; on beş yıldır kronik obstrüktif akciğer hastalığı (KOAH), üç yıldır koroner arter hastalığı (KAH) ve yaklaşık beş yıldır kalp yetmezliği mevcuttu. American Society of Anesthesiologists (ASA) IIIE riski ile operasyona alınan hastaya ultrasonografi (USG) ve periferik sinir stimülatörü eşliğinde interskalen ve yüzeyel servikal sinir bloğu planlandı. Hasta blok odasına alınıp IV damar yolu açılarak %0.9 izotonik 60 mL/saat hızında verildi. Rutin monitörizasyon işlemi yapıldı. Hastanın kalp tepe atım (KTA) hızı: 110/dk, noninvaziv tansiyon arteriyal (TA): 100/60 mmHg, SPO2: %84 idi ve yüz maskesi ile %60 O2 verildi. USG eşliğinde (MyLab 30 Gold Esaote, Italy) periferik sinir stimülatörü iğnesi (50 mm 22 G Pajunk, SonoPlex STIM) ile ilgili bölgelerde motor yanıt alındıktan sonra, 20 mL %0,5’lik bupivakain ile interskalen ve 7 mL %0,5’lik bupivakain ile servikal pleksus bloğu işlemi yapıldı. Hasta blok yapıldıktan 20 dk sonra pinprick testi sonrası operasyon masasına alınıp pozisyon verilen hastada 5 dk sonra ani kardiyak arrest gelişti. Hastanın oturur pozisyonu hemen düzeltilerek kardiyopulmoner resüsitasyon’a (KPR) başlandı endotrakeal entübasyon yapılıp 1 mg adrenalin yapıldı ve hasta 1dakikalık KPR sonrası yeniden kalp atımı görüldü. Spontan solunumu geri dönen hasta entübe halde yoğun bakım ünitesi (YBÜ)’ne alındı. Yaklaşık 3 saat sonra ekstübe edilen hasta; YBÜ’nde takip edilirken; yatışının üçüncü günü eşlik eden yandaş hastalıkları nedeniyle eksitus oldu.

Olgu 2 – Elli sekiz yaşında beş yıldır KOAH olan ve başka ek hastalığı olmayan kadın hastaya ASA II riski ile omuz artroskopisi planlandı. Hasta blok odasına alınıp IV %0.9 izotonik 100 mL/saat verildi. Rutin monitörizasyondan sonra; KTA: 72 atım/dk, TA:130/65 mmHg, SPO2: %99 (%60 maske O2 altında) olan hastaya midazolam 1 mg IV yapıldıktan sonra sinir bloğu işlemine geçildi. Hasta’ya USG ve periferik sinir stimülatörü eşliğinde 20 mL %0,5 bupivakain ile interskalen ile ilgili motor yanıt alınarak ve ayrıca, 7 mL %0,5 bupivakain ile servikal pleksus bloğu uygulandı. Yaklaşık 10 dk sonra pinprick testi ile gerekli kontroller yapıldıktan sonra hasta operasyon odasına alınarak gerekli monitörizasyon sonrası oturur pozisyona alındı. Cerrahi işlem başladıktan yaklaşık 15 dk sonra ani bradikardi, solunum arresti ve hemen sonrasında kardiyak arrest gelişti. Entübe edildi ve KPR’ye başlandı; 1mg adrenalin ile 1 dk sonra CPR’a yanıt veren hastanın spontan solunumunun geri döndüğü TEMMUZ - JULY 2020

görüldü. Hasta cerrahisi iptal edilerek YBÜ’ye alındı.

Takiplerinde bilinci açık ve koopere olduğu görülen hasta 4 saat sonra ekstübe edildi. Genel durumu stabil olan hasta YBÜ’de 24 saat takip edildikten sonra ortopedi servisine alındı.

Tartışma Periferik sinir blok teknikleri her geçen gün gelişmektedir. USG kullanımı sonrası sinir blokları daha kolay, daha güvenli yapılmakta ve daha az komplikasyon olmaktadır. Üst ekstremite sinir blokları yapılırken sinir hasarı, hematom gibi komplikasyonların dışında diğer komplikasyonlar da bilinmeli ve gerekli önlemler alınmalıdır.

Bezold-Jarisch refleksinde parasempatik aktivite artışı ve sempatik aktivite azalması nedeniyle bradikardi, hipotansiyon, vasovagal senkop ve kısa süre içinde KPR’ye cevap veren asistoli görülebilmektedir.[5,6] Bu refleks, hastalarda rejyonel anestezide, oturur pozisyon verilen interskalen ile supraklavikuler bloklarda ve genel anestezi sırasında ortaya çıkabilmektedir.[7,8] İnterskalen blok sonrası oturur pozisyonda bradikardi ve hipotansiyon sıklığının %13–29 oranında olduğu bildirilmiştir ve bu durum bir komplikasyon için ciddi ve dikkate alınması gereken bir değerdir.[9,10] Oturur pozisyonda görülen hipotansiyon, bradikardi veya asistoli sonrası hasta supin pozisyona alındığında; hasta müdahaleye çok çabuk cevap vermekte ve ortaya çıkan bulgular düzelmektedir.

Birinci vakamızda interskalen blok yapılırken bradikardi, hipotansiyon veya her hangi başka bir komplikasyon yaşanmadı. Blok uygulandıktan 25 dk ve oturur pozisyon verildikten 5 dk sonra hastada aniden asistoli gelişti. Hastanın ejeksiyon fraksiyonu (EF) %20–25 ve ileri derecede kalp yetmezliği olmasına rağmen KPR’ye hemen yanıt alındı. Hastanın yaklaşık 20 dk hiçbir komplikasyonunun olmaması, oturur pozisyona alındıktan kısa bir süre sonra aniden asistoli gelişmesi ve hastanın EF’sinin düşük olmasına rağmen KPR’ye hemen yanıt vermesi bize Bezold-Jarisch refleksini hatırlattı. İkinci hastamızın hikayesinde sadece KOAH vardı; herhangi bilinen bir kardiyak rahatsızlığı yoktu ve preoperatif monitörizasyon değerleri normaldi.

Hastamızda; interskalen blok uygulandıktan sonra yaklaşık 24 dk boyunca herhangi bir komplikasyon 169

A RI PAIN görülmedi. Oturur pozisyona alındıktan ve cerrahi başladıktan 15 dk sonra bradikardi ve ardından asistoli gelişmesi ve hasta supin pozisyona getirildikten sonra 1 dk içinde hemen KPR’ye yanıt vermesi yine bize Bezold-Jarisch refleksini hatırlatmıştır. İnterskalen blok sırasında tek taraflı frenik sinir tutulumu olabilmekte ve solunum sıkıntısı görülebilmektedir.[11,12] İki hastamızda da solunum sıkıntısı belli bir sürede gelişmemiş oturur pozisyona alındıktan sonra aniden gelişmiştir. Blok yapıldıktan sonra ilk olgumuzda 20 dk ikinci olgumuzda ise 24 dk hiçbir solunum sıkıntısı olmaması bizi frenik sinir tutulumuna bağlı solunum arresti düşüncesinden uzaklaştırmıştır. İnterskalen sinir bloğunun; hematom, lokal anestezik toksisitesi, vasküler enjeksiyon gibi komplikasyonları olmasına rağmen blok yapıldıktan sonra oturur pozisyonda Bezold-Jarisch refleksi geliştiği bilinmeli ve supin pozisyona hemen cevap verdiği unutulmamalıdır. Bu nedenle sinir bloğu teknikleri uygulanırken yakın kardiyak monitörizasyon yapılmalı, hipotansiyon, bradikardi ve kardiyak arrest durumunda ihtiyaç duyulan gerekli malzemeler hasta yakınında olmalı ve herhangi bir komplikasyon geliştiğinde ne yapılması gerektiği iyi bilinmelidir.

Hasta Onamı: Yazılı hasta onamı bu çalışmaya katılan hastadan alınmıştır.

Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması (conflict of interest) yoktur.

Hakem değerlendirmesi: Dış bağımsız.

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Kaynaklar 1. Campagna JA, Carter C. Clinical relevance of the BezoldJarisch reflex. Anesthesiology 2003;98(5):1250–60.

2. Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole: relationship to vasovagal syncope and the BezoldJarisch reflex. Br J Anaesth 2001;86(6):859–68.

3. So J, Shin WJ, Shim JH. A cardiovascular collapse occurred in the beach chair position for shoulder arthroscopy under general anesthesia -A case report-. Korean J Anesthesiol 2013;64(3):265–7.

4. Kinsella SM, Tuckey JP. Perioperative bradycardia and asystole: relationship to vasovagal syncope and the BezoldJarisch reflex. Br J Anaesth 2001;86(6):859–68.

5. Morris GN. The Bezold-Jarisch reflex. Anesth Analg 1996;83(1):201–2.

6. Aviado DM, Guevara Aviado D. The Bezold-Jarisch reflex. A historical perspective of cardiopulmonary reflexes. Ann N Y Acad Sci 2001;940:48–58.

7. Hampl KF, Schneider MC. Vasovagal asystole before induction of general anaesthesia. Eur J Anaesthesiol 1994 Mar;11(2):131–3.

8. Hart PS, Yanny W. Needle phobia and malignant vasovagal syndrome. Anaesthesia 1998;53(10):1002–4.

9. D’Alessio JG, Weller RS, Rosenblum M. Activation of the Bezold-Jarisch reflex in the sitting position for shoulder arthroscopy using interscalene block. Anesth Analg 1995;80(6):1158–62.

10. Kahn RL, Hargett MJ. Beta-adrenergic blockers and vasovagal episodes during shoulder surgery in the sitting position under interscalene block. Anesth Analg 1999;88(2):378–81.

11. Baskan S, Taspinar V, Ozdogan L, Gulsoy KY, Erk G, Dikmen B, et al. Comparison of 0.25% levobupivacaine and 0.25% bupivacaine for posterior approach interscalene brachial plexus block. J Anesth 2010;24(1):38–42.

12. Rettig HC, Gielen MJ, Jack NT, Boersma E, Klein J. A comparison of the lateral and posterior approach for brachial plexus block. Reg Anesth Pain Med 2006;31(2):119–26.

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Agri 2020;32(3):171–174

doi: 10.5505/agri.2018.65477

A RI PAIN

OLGU SUNUMU / CASE REPORT

Tolosa-Hunt Sendromu; kliniği, kranyal MR özellikleri ve tedavisi Tolosa-Hunt Syndrome; clinical and brain MRI features and treatment Asuman ALI,

Ramazan YALÇIN

Özet Tolosa-Hunt Sendromu (THS), periorbital ve hemikranyal ağrı ile ortaya çıkan, ipsilateral okülomotor ve altıncı kranyal sinir tutulumunun görüldüğü, steroidlere iyi cevap veren, orbitanın tepe kısmında veya kavernöz sinüste granülomatöz inflamasyonun gözlendiği idyopatik bir durumdur. 25 yaşında erkek hasta, sol göz çevresinde şiddetli, yanıcı, yakıcı ağrı, çift görme yakınmaları ile başvurdu. Sol gözünde semipitoz, dışa bakış kısıtlılığı, aşağı dışa bakmakta güçlük mevcuttu. Travma ve ilaç kullanma öyküsü yoktu. Kranyal Manyetik Rezonans(MR) görüntülemesinde solda kavernöz sinüs duvarında kalınlaşma ve kontrastlı MR kesitlerinde inflamasyona bağlı yoğun boyanma tespit edildi. Serebral arteryel ve venöz anjiogramları normaldi. 1mg/kg hesabıyla metil prednisolon tedavisi parenteral olarak başlandı. Tedavisinin üçüncü gününde ağrısı geçti. Üçüncü haftada oftalmoplejisi düzelmeye başladı. Tedavisi tamamlandıktan üç ay sonra kliniği tamamen düzeldi. Kortikoterapi başlandıktan sonra ağrısı tekrarlamadı. Kliniğinin birinci ve üçüncü aylarında kranyal MR’ları karşılaştırmalı olarak değerlendirildi. İnflamasyonun düzeldiği görüntülendi. Ağrılı oftalmopleji olgularında THS her zaman akılda tutulmalıdır. Orbitanın verteksinde etkilenme yoksa, özellikle kavernöz sinüse yönelik kranyal MR incelemesi yeterli olmakta ve tanı koydurucu özellik taşımaktadır.

Anahtar sözcükler: Ağrılı oftalmopleji; kranyal MR; Tolosa-Hunt sendromu.

Summary Tolosa-Hunt Syndrome (THS) is an idiopathic condition characterized by periorbital and hemicranial pain, ipsilateral oculomotor and sixth cranial nerve involvement, good response to steroids, granulomatous inflammation of the cavernous sinus or the top of the orbita. A 25 year- old- male patient presented with severe burning burn pain near the left eye with double vision. The left eye exhibited semiptosis, limited outward gaze, and difficulty in the downward outward gaze. No history of trauma or drug use was reported. Cranial Magnetic Resonance Imaging (MRI) showed thickening cavernous sinus walls to the left, while contrasted MRI sections suggested inflammation as indicated by intense staining. Cerebral arterial and venous angiography were normal. Parenteral treatment with 1mg/kg methylprednisolon commenced. The pain passed on the third day of treatment. Ophthalmoplegia began improving in the third week. The clinical symptoms were completely over after the third month of the clinic. The pain did not recur after corticotheraphy started. The cranial MRI of the patient was reviewed in a comparative perspective in the first and third months of the clinic. Inflammation was observed to get better. THS should always be considered in painful ophthalmoplegia cases. Cranial MRI towards the cavernous sinus, in particular, would suffice for diagnosis, provided that the vertex of orbita is not affected.

Keywords: Painful ophthalmoplegia; cranial MRI; Tolosa-Hunt syndrome.

Giriş Tolosa Hunt sendromu (THS), nadir görülen ağrılı bir oftalmoplejidir. Sendromun kendine özel biyolojik belirteci yoktur. Tanı klinik bulgulara ve nöroradyolojik özelliklere göre konur. Ancak başlangıçta sadece çok şiddetli ağrı ile ortaya çıkması, dolayısıyla erken tanı problemlerine yol açmakta ve tedavisi özellik göstermektedir. Ağrıya birkaç gün içerisinde kranyal

sinir tutulumları da eklenince olgular daha karmaşık hale gelmektedir. Kavernöz sinüsün veya orbita apeksinin nonspesifik granülomatöz inflamasyonundan kaynaklanır. Üç, dört ve altıncı kranyal sinirlerin oftalmoparezisinin eşlik ettiği tek taraflı retro veya periorbital ağrıyla ortaya çıkar. Oftalmoplejinin başlamasıyla birlikte ağrı görülebilir. Veya tipik olarak ağrı başladıktan sonra iki hafta içinde oftalmopleji gelişir.

T.C. Sağlık Bilimleri Üniversitesi, Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Nöroloji Kliniği, Bursa BURTOM, Bursa Radyolojik Tanı Merkezi, Bursa 1 Department of Neurology, Health Sciences University Yüksek İhtisas Training and Research Hospital, Bursa, Turkey 2 Department of Radiology, Radiological Diagnostic Center, Bursa, Turkey 1 2

Başvuru tarihi (Submitted) 18.11.2017 Düzeltme sonrası kabul tarihi (Accepted after revision) 11.04.2018 Online yayımlanma tarihi (Available online date) 04.10.2018

İletişim (Correspondence): Dr. Asuman Ali. Sağlık Bilimleri Üniversitesi, Yüksek İhtisas Eğitim ve Araştırma Hastanesi, Nöroloji Kliniği, Bursa, Turkey.

Tel (Phone): +90 - 224 - 295 50 00 e-posta (e-mail): asumanali@gmail.com © 2020 Türk Algoloji Derneği

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A RI PAIN pabilecek başka sebepleri düşünerek hematolojik testler yapılmalıdır. Tam kan sayımı, eritrosit sedimantasyon hızı, antinükleer antikor ve antinötrofil sitoplazmik antikor ve ACE (anjiotensin-converting enzim) düzeylerine bakılabilir. Beyin omurilik sıvısı (BOS) incelemesi yapılabilir ve normal olması gerekir.

Doku biyopsisi, kortikosteroide cevap alınmadığında veya değişmeyen anormal radyolojik incelemelerde, progresyon gösteren hastalarda düşünülmelidir.[5–7] Kortikosteroidlere derhal cevap alınması Tolosa Hunt sendromu için ayırt edici bir özelliktir.[7–9] Şekil 1. Hastanın sol gözünde semipitoz görülüyor.

Trigeminal sinirin maksiller ve mandibüler dalları ile periarteryel sempatik tutulum da olabilir. Yaş, cinsiyet veya etnik ayrım gözetmez. Olguların %85’inde spontan remisyon bildirilmiştir. Ancak nüks de sık görülür. Tedavi edilen olguların %40’ında aylar, yıllar sonra bile nüks görülebilir. Tanı ölçütleri epizodik tek taraflı orbital ağrıdır. Tedavi edilmezse haftalarca devam eder ve üçüncü, dördüncü veya altıncı kranyal sinirlerin bir veya daha fazla dalının paralizisi ağrıya eşlik eder. Kranyal MR da veya doku biyopsisinde granülomanın gösterilmesiyle tanı kesinleşir. Bu bilgilerin ışığında olgunun sunulması amaçlanmıştır.[1–4] Tanı için aksiyal ve koronal kranyal manyetik rezonans görüntüleme çalışması yapılmalıdır. Etkilenen kavernöz sinüste kontrast tutulumu ve kalınlaşma tipik olarak ortaya konur. Anevrizma, arteryovenöz malformasyon veya arteryovenöz fistül ayırıcı tanısı için serebral anjiografi yapılabilir. İnflamasyon ya-

(a)

(b)

Olgu Sunumu 25 yaşında erkek hastaydı. Sol göz çevresinde şiddetli, yanıcı, yakıcı ağrı, çift görme yakınmaları ile başvurdu. Kliniğe kabul edildiğinde vital bulguları normaldi. Nörolojik muayenesinde solda dışa bakış kısıtlılığı mevcuttu. Solda altıncı sinir paralizisi ile uyumluydu ve ayrıca semipitozu vardı ve aşağı dışa bakmakta güçlük çekiyordu (Şekil 1). Travma ve ilaç kullanma öyküsü yoktu. Solda trigeminal sinirin oftalmik dağılım alanına uyan ağrı yakınması mevcuttu. Papilla ödemi yoktu. Motor, duyu ve serebellar testleri, tam kan sayımı, temel metabolik paneli, mikrobiyolojik tetkikleri ile beyin omurilik sıvısı ve koagülasyon incelemeleri normaldi. CRP, RF ve vaskülit testleri, ASO ve tümör belirteçlerinde de özellik yoktu.

Kranyal MR görüntülemesinde solda kavernöz sinüs duvarında kalınlaşma ve kontrastlı MR kesitlerinde inflamasyona bağlı yoğun boyanma tespit edildi (Şekil 2). Serebral arteryel ve venöz anjiogramları nor-

(c)

Şekil 2. Kontrastlı kraniyal T1A koronal kesitler. (a) Hasta ilk geldiğinde çekilen MR’da sol kavernöz sinüste yoğun boyanan granülasyon dokusu görülüyor. (b) Tedavi sonrası 1. ayda kontrol MR’da lezyon gerilemiş. (c) 3 ay sonraki MR’da lezyonun daha da küçüldüğü görülüyor.

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Tolosa-Hunt Sendromu; kliniği, kranyal MR özellikleri ve tedavisi

maldi. 1mg/kg. hesabıyla metil prednisolon tedavisi parenteral olarak başlandı. 40 mg. metil prednisolon ampul sabah akşam intravenöz yolla uygulandı.

Tedavisinin üçüncü gününde ağrısı geçti. Tedavi üç hafta süreyle yapıldı. Her hafta metil prednisolon dozu 10 mg. azaltıldı. Üçüncü haftanın sonunda 32 mg. oral tablet ile taburcu edildi. Taburculuk sonrası oral tabletin üçüncü dozundan sonra gün aşırı üç doz 16 mg. tablet verilerek tedavi sonlandırıldı. Tedavi süresince komplikasyon olmadı. Tuzsuz diyet harfiyen uygulandı ve kalsiyum desteğine özel önem verildi. Oral antifungal tedavi ile profilaksi yapıldı. Üçüncü haftada oftalmoplejisi düzelmeye başladı.

Tedavisi tamamlandıktan üç ay sonra kliniği tamamen düzeldi. Kortikoterapiye başlandıktan sonra ağrısı tekrarlamadı. Kliniğinin birinci ve üçüncü ayında Kranyal MR’ları karşılaştırmalı olarak değerlendirildi. İnflamasyonun düzeldiği görüntülendi.

ağrılı oftalmoplejiye neden olabilir. Ancak hikaye ve radyolojik incelemeler tanı koydurur.

Tartışma

Sarkoidoz, birden fazla kranyal sinir tutulumu varlığında ayırıcı tanıda düşünülmelidir. Tanıda laboratuar bulgularından kan ve BOS-ACE düzeyleri, kalsiyum düzeyi ve akciğer grafisi ile toraks BT yardımcı olur.

Tolosa Hunt sendromu, çok acı veren, can sıkıcı, saplayıcı, şimşek çakar gibi şiddetli devamlı ağrı ile ortaya çıkan bir klinik tablodur. Tanı kriterleri Uluslararası Baş Ağrısı Derneği (IHS) nin 2004’te güncellenen kriterlerine göre belirlenmiştir. Kortikosteroid tedavisini takiben ağrının azalması karakteristik bir özelliğidir. Bizim olgumuz da kortikosteroid tedavisine çok iyi cevap vermiş ve 72 saatte ağrısı geçmiştir. Diğer ana semptom bir veya daha fazla kranyal sinirde paralizidir. Ancak steroidlerin kranyal sinir paralizisi üzerine etkisi, ağrı üzerine olan etkisiyle kıyaslandığında daha azdır.[1–4] Kavernöz sinüslerden geçen üçüncü, dördüncü, altıncı sinir ile beşinci kranyal sinirin birinci dalı etkilenmektedir. Periarteryel sempatik lifler ve optik sinir de tutulabilir. Bizim olgumuzda periarteryel sempatik liflerde ve optik sinirde tutulum yoktu ancak trigeminal sinirin oftalmik dalı etkilenmişti. Bu durum kavernöz sinüsün lateral duvarının etkilendiğini göstermekte ve superior orbital fissüre sınırlı olan lezyonlardan ayırıcı tanısı yapılabilmektedir.[5–7] Tolosa Hunt sendromu ayırıcı tanısında travma, karotikokavernöz fistül, tümörler, vaskülit, bazal menejitis, sarkoidoz, oftalmoplejik migren ve vasküler nedenler üzerinde durulmaktadır.[8,9] Okülomotor sinirin hasar gördüğü kafa travmaları, TEMMUZ - JULY 2020

Karotikokavernöz fistülde orbital ağrıya, propitozis, kemozis, göz içi basınç artışı ve retinal damar anormallikleri eşlik eder. Serebral anjiografi ile tanısı konabilir. Posterior serebral arter anevizmaları da THS’unu taklit edebilir.

Oftalmoplejik migrende migren atakları sırasında 3., 4. ve 6. kranyal sinir tutulumları gözlenir. Baş ağrısının geçmesiyle genellikle kranyal sinir paralizileri de düzelir. 5. kranyal sinir tutulumu olmamasıyla THS’dan ayırıcı tanısı yapılır.

Primer intrakranyal tümörler veya nazofaringeal tümör gibi lokal, lenfoma gibi uzak metastatik tümörler de ağrılı oftalmopleji yapabilir.

Özellikle nörotüberküloza bağlı bazal menenjitis de ayırıcı tanıda incelenmesi gereken klinik tablosu ile ağrılı oftalmopleji ve kranyal sinir tutulumlarına yol açar.

Kranyal MR incelemelerinde ipsilateral kavernöz sinüs içinde granülomatoz lezyon ve kavernöz sinüsde genişleme gösterilebilir. Nadiren orbitanın posterioruna ve apeksine doğru uzanabilir. Bizim olgumuzda sol kavernöz sinüs bölgesinde sağa göre asimetrik genişleme ve kontrast sonrası yoğun boyanma gözlendi. MR bulguları doğrultusunda Tolosa-Hunt sendromu tanısı konarak tedavi başlandı. 1 ay sonraki kontrol MR’da lezyon boyut ve yaygınlığında gerileme olduğu tespit edildi. 3 ay sonraki kontrol MR’da lezyonda çok daha fazla gerileme olduğu görüldü.

Sonuç olarak, Tolosa Hunt sendromu, non-spesifik kronik granülomatöz inflamatuar lezyondan kaynaklanır. Kavernöz sinüsü veya orbita ve orbita apeksini tutar. Kavernöz sinüsün içinden geçen bir veya birden fazla kranyal sinir paralizisi ortaya çıkar. Yüksek rezolüsyonlu MR çalışmalarında lezyon genellikle orbita apeksi veya kavernöz sinüs içinde gösterilebilir.

Steroid tedavisiyle lezyonun kaybolmaya başladığını ortaya koymak önem taşımaktadır.

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A RI PAIN Hasta Onamı: Olgu sunumunun ve beraberindeki görüntülerin yayınlanması için yazılı bilgilendirilmiş onam alındı.

Yazar(lar) ya da yazı ile ilgili bildirilen herhangi bir ilgi çakışması (conflict of interest) yoktur.

Hakem değerlendirmesi: Dış bağımsız.

Kaynaklar 1. Kline LB, Hoyt WF. The Tolosa-Hunt syndrome. J Neurol Neurosurg Psychiatry 2001;71:577–82.

2. Zhang X, Zhang W, Liu R, Dong Z, Yu S. Factors that influence Tolosa-Hunt syndrome and the short-term response to steroid pulse treatment. J Neurol Sci 2014;341 (1-2):13–6.

3. Zurawski J, Akhondi H. Tolosa-Hunt syndrome--a rare cause of headache and ophthalmoplegia. Lancet 2013;382 (9895):912.

4. Anagnostou E, Kouzi I, Kararizou E. Painful ophthalmople-

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gia: the role of imaging and steroid response in the acute and subacute setting. J Neurol Sci 2013;331(1-2):145–9.

Jain R, Sawhney S, Koul RL, Chand P. Tolosa-Hunt syndrome: MRI appearances. J Med Imaging Radiat Oncol 2008;52(5):447–51.

Schuknecht B, Sturm V, Huisman TA, Landau K. TolosaHunt syndrome: MR imaging features in 15 patients with 20 episodes of painful ophthalmoplegia. Eur J Radiol 2009;69(3):445–53.

Dornan TL, Espir ML, Gale EA, Tattersall RB, Worthington BS. Remittent painful ophthalmoplegia: the Tolosa-Hunt syndrome? A report of seven cases and review of the literature. J Neurol Neurosurg Psychiatry 1979;42(3):270–5.

Kodera T, Takeuchi H, Arishima H, Tsunetoshi K, Kitai R, Arai Y, et al. Microsurgical findings of Tolosa-Hunt syndrome.

World Neurosurg 2013;79(3-4):594.e1–4.

Yazıcı I, Sarıteke A, Zorlu Y. Tolosa-Hunt sendromu ve diyabetik kraniyal mononöropati birlikteliği: Olgu sunumu ve gözden geçirme. Ağri 2014;26(2):87–92.

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Agri 2020;32(3):175–176

doi: 10.14744/agri.2019.92170

A RI PAIN

LETTER TO THE EDITOR

A new treatment modality in piriformis syndrome: Ultrasound guided dry needling treatment Piriformis sendromunda yeni bir tedavi modalitesi: Ultrason rehberliğinde kuru iğneleme tedavisi Fatih BAĞCIER,1

Fatih Hakan TUFANOĞLU2

To the Editor, The article titled, “Reflex sympathetic dystrophy secondary to piriformis syndrome: a case report.”[1] Published in April 2009, while discussing the treatments for piriformis syndrome in the article, ultrasound-guided dry needling (DN) treatment was not mentioned. DN treatment, as being more popular recently, has become a part of our practices.

A 54-year-old male patient was admitted to the clinic with the complaints of pain, numbness and tingling, which the patient had been experiencing for the last 1 year, at the waist and spreading behind the buttocks and thighs. The patient’s pain was mechanical and increased if standing and sitting for a long time and decreased with resting in lying position. He had no known history of trauma and on physical examination, he did not have any paravertebral muscle spasm in the lumbar region. No trochanter major and interspinal distance sensitivity was detected. Faber and Fadir tests that evaluate sacroiliac and hip joint were bilateral negative. There was sensitization with deep palpation in the right gluteal region. Frieiberg and Pace tests were positive on the side having pain.

Visual analogue scale (VAS) value was 7 out of 10. Oswestry disability index (ODI) score was 78. Magnetic resonance imaging of the hip region was requested for the exclusion of other possible pathologies with a preliminary diagnosis of piriformis syndrome (PS).

Figure 1. Ultrasound guided dry needling treatment of piriformis syndrome.

No pathology was detected, and the patient was diagnosed with PS. Prior to medical treatment (myorelaxant, non-steroidal anti-inflammatory, pregabalin), the patient was planned to receive ultrasoundguided DN (Fig. 1). In addition, stretching exercises for piriformis muscle were recommended. DN was performed one session per week, 3 times in total.

Pregabalin treatment was started for neuropathic pain. In the first month of the treatment, a follow-up examination was performed. The patient’s VAS value decreased to 2/10 and ODI score decreased to 35.

PS is the cause of non-discogenic sciatica caused by compression of the sciatic nerve under piriformis

Departmant of Physical Medicine and Rehabilitation, Kars Harakani State Hospital, Kars, Turkey Department of Radiology, Sarıkamış State Hospital, Kars, Turkey

1 2

Submitted: 04.05.2019 Accepted after revision: 18.11.2019 Available online date: 04.06.2020

Correspondence: Dr. Fatih Bağcıer. Kars Harakani Devlet Hastanesi, Fiziksel Tıp ve Rehabilitasyon Kliniği, 36100 Kars, Turkey.

Phone: +90 - 544 - 242 90 42 e-mail: bagcier_42@hotmail.com © 2020 Turkish Society of Algology

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A RI PAIN muscle for structural or acquired reasons. Myofascial trigger points (MTrP) are the most common ones in its etiology, and there are anatomical variations of the hypertrophy, inflammation, trauma, piriformis muscle or sciatic nerve in its muscle tissue.[2] Conservative approaches such as lifestyle changes, medical therapy, physical therapy modalities and exercise therapy are generally successful in its treatment. In patients with resistance, interventional procedures (such as dry needling, steroid-local anesthetic injection) may be applied. DN treatment is a treatment method where MTrPs are stimulated using acupuncture needles or injection needles.[3] It can be performed according to anatomical indicators, as well as with ultrasound and fluoroscopy. It can also be performed with blinding, but the success probability of reaching the right region with this method is low compared to the ultrasound-guided DN. Besides, there is a risk of damaging neighboring neurovascular structures. Finnoff et al.[4] compared ultrasound and fluoroscopy as a guide for PS injection in their study. They found the success rate of ultrasound to be 95% and fluoroscopy to be 35%. Fusco et al.[5] administered ultrasound-guided dry needling treatment to three patients with piriformis syndrome and obtained improvement in pain and functionality parameters. Our approach is different from this study in two aspects. Fusco et al.[5] administered an average of 8 sessions of DN treatment to 3 patients in 10 days. The size of the needle they used was 0.30x60 mm. In our study, we performed 3 sessions with one-

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week interval and used a thicker needle with a size of 0.60x60 mm. There is no clear treatment frequency for DN in the literature. We think that our practice is less invasive, more cost-effective and an approach that improves patient compliance.

In conclusion, DN should be included in our treatment modalities as a microinvasive, inexpensive and effective method in the treatment of PS. With the use of ultrasound, which is called as “my extended hand”, “my sixth finger”, “complementary examination” by the physicians in clinical practice, its success will increase.

References 1. Akçali D, Taş A, Cizmeci P, Oktar S, Zinnuroğlu M, Arslan E, Köseoğlu H, Babacan A. Reflex sympathetic dystrophy secondary to piriformis syndrome: a case report. Agri 2009;21(2):75–9.

2. Külcü DG, Mesci N, Batıbay SC, Taraktaş, Aktaş İ. Evaluation of Short-term Effectiveness of Ultrasound-guided Injection in Treatment of Piriformis Syndrome. Bosphorus Med J 2017;4(1):4–7.

3. Akkurt S. Kuru İğneleme. Turkiye Klinikleri Journal of Sports Medicine-Special Topics 2018;4(1):56–9.

4. Finnoff JT, Hurdle MF, Smith J. Accuracy of ultrasoundguided versus fluoroscopically guided contrast-controlled piriformis injections: a cadaveric study. J Ultrasound Med 2008;27(8):1157–63.

5. Fusco P, Di Carlo S, Scimia P, Degan G, Petrucci E, Marinangeli F. Ultrasound-guided Dry Needling Treatment of Myofascial Trigger Points for Piriformis Syndrome Management: A Case Series. J Chiropr Med 2018;17(3):198–200.

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